SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA ASSESSING THE QUALITY OF ANTENATAL CARE SERVICES IN THE NKWANTA SOUTH DISTRICT, VOLTA REGION, GHANA BY DEGLEY, JOSEPH KWAMI (10363558) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTERS OF PUBLIC HEALTH DEGREE JULY, 2012 University of Ghana http://ugspace.ug.edu.gh i DECLARATION I declare that this dissertation is the result of my own research work. Where my work is indebted to the work of others, I have made acknowledgement. I also declare that this work has neither been accepted in substance for the award of other degree nor is it concurrently being submitted for any other degree. ACADEMIC SUPERVISOR Dr. Reuben Esena ………………….…………………..……. Date:………………..… Signature CANDIDATE Degley, Joseph Kwami ………..………………………..…………… Date:……………………… Signature University of Ghana http://ugspace.ug.edu.gh ii DEDICATION This study is dedicated to my wife Mrs. Vida Petershie-Degley and our daughters, Amenuveve, Edzordzinam, Sedem and Anita for their endurance, support and encouragement throughout my study period. University of Ghana http://ugspace.ug.edu.gh iii ACKNOWLEDGEMENTS I thank God for seeing me through this course. I would like to express my warmest gratitude to my academic supervisor, Dr. Reuben Esena for his immeasurable support and constructive guidance throughout the study. My special thanks go to Dr. Anthony Ashinyo, my field supervisor and the entire membership of Nkwanta South DHMT especially, Mr Adamu Issaka, the District Disease Control Officer, Miss Ruth Dormediameo, the District Nutrition Officer, Mr. McLinus Dzata, the Administrator and Madam Annie Ofori, the District Public Health Nurse for their support in diverse ways. My gratitude also goes to Sister Rose Suma, the Administrator of the St. Joseph’s Hospital, Nkwanta, the facility in-charges of Breweniase and Tutukpeni Health Centres, Bonakye and Kecheibi CHPS compounds for allowing me and my teams to spend days in their facilities to collect data for the study. I would like to express my appreciation to Dr. Mawuli Dzordzormenyo and all my fellow 2012 MPH classmates especially those with whom I went to Nkwanta South District Health Directorate (Stephen Selasie Akakpo, Georgia T. Mitchell and Ellen Klutse) for the various roles they played in fruition of this study. Finally, it is my pleasure to thank my research assistants and the various authors from whose work I extracted very valuable information to make the study. University of Ghana http://ugspace.ug.edu.gh iv ABSTRACT Introduction: Quality Antenatal Care is serious concern in Ghana and can be achieved through a planned set of actions designed to provide clients with the services they expect. This study assessed and described the quality of antenatal care and clients’ satisfaction at public health facilities in the Nkwanta South District. Methods: The study was a cross sectional survey. Two hundred and seventy eight (278) pregnant women were interviewed using a structured questionnaire. A checklist was used to assess availability of resources. Qualitative data was collected through focus group discussions. Quantitative data was analyzed by SPSS version 16.0 while qualitative data was analyzed using thematic analysis. The quality of ANC measured was based on Ghana National Reproductive Health standards using available infrastructure, materials and supplies. Results: The results show that, majority of the respondents (96.4%) were “willing to come back to the ANC clinics before delivery”. The results further show that, 89.6% of the total respondents perceived the care they received as “quality” while 87.3% said they were generally satisfied with ANC services. It was also found that, with the exception of age (p= 0.161), all the other clients’ personal characteristics like marital status (p <0.05), educational level (p <0.05), occupation (p <0.05) and religion (p <0.05) had a significant effect on clients’ appreciation of satisfaction leading to an overall quality rating. Conclusion and recommendation: Generally, quality of antenatal care services was overall perceived as “good” (89.6%) with respect to the national standards. Nonetheless, the structure at all the facilities ought to be upgraded to support care of pregnant women. There is also the need to sensitize the staff and the communities on Focus Antenatal Care. University of Ghana http://ugspace.ug.edu.gh v TABLE OF CONTENTS Content Page DECLARATION ................................................................................................................. i DEDICATION .................................................................................................................... ii ACKNOWLEDGEMENTS ............................................................................................... iii ABSTRACT ....................................................................................................................... iv TABLE OF CONTENTS .................................................................................................... v LIST OF TABLES ............................................................................................................. ix LIST OF ABBREVIATIONS ............................................................................................ xi DEFINITION OF TERMS .............................................................................................. xiii CHAPTER ONE ................................................................................................................. 1 INTRODUCTION .......................................................................................................... 1 1.1 Background ........................................................................................................... 1 1.2 Statement of the Problem ...................................................................................... 3 1.3 Justification of the Study ...................................................................................... 3 1.4 Objectives ............................................................................................................. 4 1.4.1 General Objective .............................................................................................. 4 1.4.2 Specific Objectives ............................................................................................ 4 1.5 Conceptual Framework ....................................................................................... 6 CHAPTER TWO ................................................................................................................ 7 LITERATURE REVIEW ............................................................................................... 7 2.1 Introduction ........................................................................................................... 7 2.2 Quality Health Care .............................................................................................. 7 2.3 Available infrastructure and resources for ANC in Ghana ................................... 8 University of Ghana http://ugspace.ug.edu.gh vi 2.4 The role of resources in quality ANC services ..................................................... 9 2.5 Upgrading Skills for better service ..................................................................... 11 2.6 Benefits of quality ANC process ........................................................................ 12 2.7 Focused Antenatal Care ...................................................................................... 14 2.8 Consequences of poor ANC practices ................................................................ 15 2.9 Client’s perception of quality ANC .................................................................... 17 CHAPTER THREE .......................................................................................................... 18 METHODOLOGY ....................................................................................................... 18 3.1 Type of Study ...................................................................................................... 18 3.2 Study Area .......................................................................................................... 18 3.3 Study Population ................................................................................................. 20 3.3.1 Inclusion Criteria ............................................................................................. 20 3.4 Study Variables ................................................................................................... 20 3.5 Sample Size ......................................................................................................... 20 3.5.1 Sample Size Calculation .................................................................................. 20 3.6 Sampling Methods .............................................................................................. 21 3.7 Subject Selection ................................................................................................. 21 3.8 Training of Data Collectors ................................................................................ 22 3.9 Data Collection Methods .................................................................................... 22 3.10 Data Management and Analysis ....................................................................... 24 3.11 Quality Control ................................................................................................. 25 3.12 Ethical Considerations ...................................................................................... 25 3.13 Study Limitations .............................................................................................. 26 University of Ghana http://ugspace.ug.edu.gh vii CHAPTER FOUR ............................................................................................................. 27 RESULTS ......................................................................................................................... 27 4.0 Introduction ............................................................................................................. 27 4.1 Response Rate by Facilities .................................................................................... 27 4.2 Demographic Characteristics of the Respondents .................................................. 28 4.3 Structural resources available at the health facilities .............................................. 30 4.4 Assessment of quality perspective dimensions (provider skills and practices) ...... 33 4.4.1 Empathy ........................................................................................................... 33 4.4.2 Communication ................................................................................................ 34 4.4.2.1. Information Adequacy ................................................................................. 35 4.4.3 Competence of Providers ................................................................................. 37 4.4.4 Availability of some essential resources .......................................................... 38 4.4.5 Tangibles .......................................................................................................... 40 4.4.6 Responsiveness ................................................................................................ 42 4.5 General Rating of Quality of care and Client Satisfaction ................................. 44 4.6 Multinomial logistic regression analysis ............................................................ 45 4.6.1 Multinomial logistic regression of patients’ characteristics and providers’ skills and practices .............................................................................................................. 45 4.6.2 Multinomial logistic regression of clients’ perception of satisfaction and quality of care ........................................................................................................... 47 CHAPTER FIVE .............................................................................................................. 51 DISCUSSIONS ............................................................................................................. 51 5.1 Type of Facility and Resources Available .......................................................... 51 University of Ghana http://ugspace.ug.edu.gh viii 5.2 Assessment of Quality Perspective (Providers’ Skills and Practices) ................ 52 5.2.1 Empathy ........................................................................................................... 52 5.2.2 Communication ................................................................................................ 53 5.3.3 Competence ...................................................................................................... 53 5.2.4 Availability of Resources ................................................................................. 54 5.2.5 Tangibles .......................................................................................................... 54 5.2.6 Responsiveness ................................................................................................ 54 5.2.7 Overall Satisfaction and Quality ...................................................................... 55 CHAPTER SIX ................................................................................................................. 57 CONCLUSION AND RECOMMENDATION ............................................................ 57 6.1 Conclusion .......................................................................................................... 57 6.2 Recommendations ............................................................................................... 58 REFERENCES ................................................................................................................. 59 APPENDICES .................................................................................................................. 64 Appendix 1 Consent form ............................................................................................. 64 Appendix 2 Structured questionnaire ........................................................................... 67 Appendix 3 Observation checklist ................................................................................ 72 Appendix 4 Focus group discussion guide ................................................................... 77 Appendix 5 Verbatim transcription of FGD sessions ................................................... 79 Appendix 6 Ethical clearance ....................................................................................... 91 University of Ghana http://ugspace.ug.edu.gh ix LIST OF TABLES Table 1 Survey response rate by facility………………………………………… 27 Table 2 Socio-demographic characteristics of respondents ………………… …. 30 Table 3 General Infrastructure Rating for Antenatal Services ………………......32 Table 4 Empathy offered by providers………………………………………….. 34 Table 5 Communication between clients and respondents……………………… 37 Table 6 Competence of providers ………………………………………………..39 Table 7 Resource availability ………………………………………………….…40 Table 8 Tangibles in health care providers setting ……………………………....42 Table 9 Responsiveness of health care providers…………………….….……….44 Table 10 Multinomial logistic regression of client characteristics and provider skills and practices ……………………………………........................ 47 Table 11 Clients perception of satisfaction and quality of care …………………. 49 University of Ghana http://ugspace.ug.edu.gh x LIST OF FIGURES Figure 1: Conceptual Framework 5 Figure 2: Map of Nkwanta South District 19 University of Ghana http://ugspace.ug.edu.gh xi LIST OF ABBREVIATIONS ANC - Antenatal Care CHAG - Christians Health Association of Ghana CHO - Community Health Officer CHPS - Community-Based Health Planning and Services DHMT - District Health Management Team FANC - Focus Antenatal Care FGD - Focus Group Discussion GDHS - Ghana Demographic Health Survey GHS - Ghana Health Services GMHS - Ghana Maternal Health Survey GNSMP - Ghana National Safe Motherhood Protocol HIV - Human Immunodeficiency Virus ICD - Institutional Care Division IPT - Intermittent Preventive Treatment MMR - Maternal Mortality Rate MOH - Ministry of Health MTCT - Mother to Child Transmission NHI - National Health Insurance PMTCT - Prevention of Mother to Child Transmission QA - Quality Assurance SPSS - Statistical Package for Social Sciences STD - Sexually Transmitted Diseases University of Ghana http://ugspace.ug.edu.gh xii STI - Sexually Transmitted Infections UNFPA - United Nations Fund for Population Activities. UNICEF - United Nations Children Emergency Fund USAID - United States Agency for International Development VDRL - Venereal Diseases Research Laboratory WHO - World Health Organization University of Ghana http://ugspace.ug.edu.gh xiii DEFINITION OF TERMS Antenatal care Care provided to a pregnant woman throughout pregnancy by a professional or non professional Empathy Caring and individualized attention provided to clients Grandmultipara A woman who has had more than four pregnancies Maternal care Care provided at a health facility during antenatal, labour and delivery and postnatal period Primigravida A woman with first pregnancy Responsiveness Willingness of the providers to help clients and provide prompt service Tangibles Physical facilities, equipment and appearance of personnel University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.1 Background Quality antenatal care (ANC) is a serious concern in Ghana and can be achieved through a planned set of actions designed to provide clients with the services they expect. It also requires an assessment of the services provided. Furthermore, the success of ANC depends on client perception of the quality of health care. Client perception during ANC not only ensures compliance but also re-enforces continuous utilization of the health facilities such as delivery and postnatal care services. Although knowledge and experience in enhancing the quality of health care has accumulated globally over many decades, there are still difficulties in achieving perfect antenatal care systems in low income countries due to the lack of resources (Pathmanathan et al., 2003). It is not surprising that antenatal clients avoid local ANC units because of perceived low quality service (Maquad, 2006). Because of this perception, they rather access geographically distant private facilities/services where they end up paying more for ANC. In an effort to improve on quality antenatal care in the country, Ghana Health Services (GHS) started the implementation of Quality Assurance (QA) programme in 1999. The QA programme focuses on client-centred care. One of the main indicators of the programme has been the measurement of client satisfaction at antenatal care units. In the Volta region, the QA programme started in 2003 with the formation of QA teams in the hospitals to monitor and support service delivery including antenatal care. University of Ghana http://ugspace.ug.edu.gh 2 Currently, the QA teams have transformed into peer-review teams under the Institutional Care Division (ICD) of the Ghana Health Services; the division responsible for clinical care. One of the functions of the peer-review teams is to conduct quality assurance in antenatal care and use the data to improve quality in ANC provision. Although this has been going-on it is now limited only to the hospitals in the region. Furthermore, peer-review meetings which are supposed to be organized four times in a year in every hospital in the region, was organized only once at Nkwanta District hospital in 2011 (DHMT, 2011). No peer-review meetings on ANC were organized in other health facilities at the sub-district levels due to non-availability of teams. Apart from the routine health service data, no assessment has been done on quality of care in the district. The purpose of this study therefore, is to assess the quality of ANC at the health facilities in Nkwanta South district in order to identify gaps for improvement. University of Ghana http://ugspace.ug.edu.gh 3 1.2 Statement of the Problem It has been noted that provider-client relationship has been poor in the country resulting in growing concern among clients about the quality of ANC care (MOH and GHS, 2007). However, the MOH & GHS (2007) survey report reveals that some facilities are efficient, delivering quality services and being responsive to the needs of their clients, but many are not. To monitor and improve the quality of antenatal care in the health facilities, the GHS recommends quality assurance (QA) surveys in health facilities at least two (2) times in a year. Although the District Health Management Team has conducted some monitoring and support surveys, their annual reports show that it has not been able to conduct 2 support visits as stipulated in the GHS calendar in a year (DHMT, 2011). The annual reports also lack data on quality of ANC services in the facilities. Furthermore, the peripheral facilities in the district do not conduct monitoring nor assess data on ANC quality. It is therefore not known how sustainable quality improvement efforts have been throughout previous years. Consequently, there is no baseline data available on ANC quality in the Nkwanta South District. 1.3 Justification of the Study This study is justified because: 1. There is no data available for the quality of ANC in the Nkwanta South District. 2. The level of ANC quality was not known in the Nkwanta South District. University of Ghana http://ugspace.ug.edu.gh 4 3. ANC practices that clients perceived as quality was also not known. This study therefore describes ANC services and resources, care providers’ skills and practices as a means of measuring quality of ANC care in the health facilities in the Nkwanta South District. Besides evaluating resource availability and providers’ skills and practices, it also elicited information on which ANC services priority areas should be chosen for improvement. This study would also help to bridge the gap between clients’ expectations and the actual services the facilities provided. This study would guide the development of policies and programmes to improve quality in ANC. Finally, the results would also form baseline data for improving quality of ANC in the Nkwanta South District. 1.4 Objectives 1.4.1 General Objective The general objective of this study is to assess the quality of antenatal care (ANC) at the public health institutions in the Nkwanta South District. 1.4.2 Specific Objectives The specific objectives are: 1. To identify available resources for providing ANC services in the institutions. 2. To assess health care providers’ skills and practices in providing ANC services. 3. To explore pregnant women’s perceptions of quality of ANC services in the facilities. University of Ghana http://ugspace.ug.edu.gh 5 Figure 1: A Modified Conceptual Framework of Quality care and its attributes adapted from Donabedian quality of Care, (1988). Provider and service characteristics Attendance Empathy Communication Competence Tangibles Responsiveness Client characteristic Age Education Marital status Religion Occupation The clients’ expectations about health care quality The clients’ experience of health care quality (previous and current) Client’s satisfaction Availability of Resources Equipment Medical consumables Drugs Vaccines Client perceived quality of care Quality care Structure Process Outcome University of Ghana http://ugspace.ug.edu.gh 6 1.5 Conceptual Framework There three main factors that influence the quality of ANC care is explained in Figure 1. These are the expectations of clients, experience of actual care they receive and availability of essential equipment/resource. Clients’ expectations are influenced by their characteristics which include age, sex, marital status, educational level and occupation. The care clients receive at the health facility is influenced by health provider characteristics such as empathy, communication, competence, tangibles and responsiveness. The third factor, equipment and resources support providers to meet the satisfaction of the clients. University of Ghana http://ugspace.ug.edu.gh 7 CHAPTER TWO LITERATURE REVIEW 2.1 Introduction The use of clients’ opinion in assessments of quality of health care has gained greater prominence over the past three years. Assessment of quality is usually done through the use of client satisfaction surveys which assess the non-technical aspects of quality of care. Integrating clients’ opinion into care provision enables health care providers meet the expectations of clients leading to higher satisfaction and subsequent compliance with instructions, education and treatment. Client satisfaction has therefore become significant objective in strategic planning process of health institutions. 2.2 Quality Health Care The assessment of quality is based on a conceptual and operationalized definition of “quality of medical care”; but quality of care is difficult to define. Perhaps the best- known definition is that by Lee and Jones (1933) which refers to the eight “articles of faith”. The eight “articles of faith” are as follows: 1. Good medical care is limited to the practice of rational medicine based on the medical sciences. 2. Good medical care emphasizes prevention. 3. Good medical care requires intelligent cooperation between the lay public and the providers of scientific medicine. 4. Good medical care treats the individual as a whole. 5. Good medical care maintains a close and continuing personal relation between care giver and patient. University of Ghana http://ugspace.ug.edu.gh 8 6. Good medical care is coordinated with social welfare work. 7. Good medical care coordinates all types of medical services. 8. Good medical care implies the application of all the necessary services of modern, scientific medicine to the needs of all the people. WHO (2006) has also given a six point working definition of quality care and suggests that a health system should seek to make improvements in six areas or dimensions of quality. These dimensions require that health care is: effective and delivering health care that is evidence based which results in improved health outcomes for individuals and communities. It should also be efficient, delivering health care in a manner which maximizes resource use and avoids waste; acceptable patient-centered, delivering health care which takes into account the preferences and aspirations of individual service users and the cultures of their communities. Furthermore, it should be equitable, delivering health care which does not vary in quality because of personal characteristics such as gender, race, ethnicity, geographical location, or socioeconomic status; safe, delivering health care which minimizes risks and harm to service users (AbouZahr, et al., 2003). 2.3 Available infrastructure and resources for ANC in Ghana In Ghana, ANC is provided by public, private and quasi-government health facilities. Structural attributes in this study include; human resources i.e. number, variety, qualification of professionals, material resources i.e. infrastructure, equipment and supplies such as sphygmomanometer, foetal scope, gestational calendar, stationary, soap, gloves tape measure, cotton and thermometer. Quality health care means providing health services to individuals and communities to improve health outcomes which should be compatible with the new professional knowledge (MOH and GHS, 2008). Quality University of Ghana http://ugspace.ug.edu.gh 9 antenatal care implies the extent to which antenatal care resources and services correspond with antenatal standards of a particular country (MOH and GHS, 2008). To provide quality ANC, the health care providers need to have adequate infrastructure, clinical skills, necessary equipment and supplies and the referral system should function well enough that women with complications get treatment as quickly as possible. The care provided should be sensitive to women and their family needs and should be satisfactory. In addition quality requires that pregnant women attend ANC as early as possible to receive the necessary care (WHO, 2007). 2.4 The role of resources in quality ANC services Availability of resources plays a useful role in provision of quality ANC. However despite the high ANC attendance in most developing countries, a major problem hindering quality of ANC is inadequate resources (Carroli, et al., 2002). In a qualitative study in Zimbabwe, using in-depth interviews health workers expressed concern over shortage of antenatal resources such as drugs, staff, electricity, telephone and dilapidated condition of the facility (Mathole, et al., 2005). Another study which assessed quality of ANC in Tanzania revealed that the quality of ANC was affected by lack of skilled staff, shortage of supplies such as drugs and inadequate stationary (AbuBakar, et al., 2006). In another study, equipment, gloves and reagents for urine testing and VDRL, infrastructure problems, and inadequate human resources to provide antenatal services have been cited as the major shortfalls in providing quality ANC in developing countries (Douglas, et al., 2007). Additionally, many facilities often the available supplies are inadequate and erratic (Amooti-Kaguna, et al., 2002). Negative approaches of health providers (Lowry, Saeger & Barnett, 1997, Safe Motherhood Project, 2002) and other factors like University of Ghana http://ugspace.ug.edu.gh 10 inadequate facility resources and organizational challenges like long waiting time (Adamu & Salihu, 2002, Pembe et al., 2010) were noted to have negative effect on overall clients’ satisfaction. Substandard care resulting from poor staff supervision, underpayment, overworking and inadequate staff training or lack of refresher courses to upgrade staff skills have been reported in some studies. A study in Zimbabwe revealed that substandard care during antenatal period (resulting from lack of skills) contributed significantly to maternal deaths (Fawcus, 1988). Similarly in Vietnam, quality of antenatal care was affected by poor staff skills (Graham, et al., 2001). The client’s perception of the care received at ANC is another important element of quality, hence a determining factor for clients’ willingness to comply with health service. In line with the notion of satisfaction and health care compliance, some researches were conducted. Some studies have reported women satisfaction with ANC (Benett, 2004). Specifically, in these studies women were satisfied with the care received, interpersonal relationship and the infrastructures for providing the care. However, other studies have revealed women dissatisfaction with ANC (Oladapo, et al., 2008, and Amooti-Kaguna B. & Nunwaha, 2002, Lowry, et al., 1997, and Mathole, et al., 2005). Also, client’s characteristics were noted to have some associations with satisfaction ratings. Although some studies have failed to find neither association between satisfaction and age (Turhal et al., 2002) nor educational status of clients (Turhal et al., 2002) other results (Olijira and Gabre-Selassie, 2001) have showed otherwise. Reasons for dissatisfaction in most of these studies were; long waiting time, inadequate medicine supply and health workers University of Ghana http://ugspace.ug.edu.gh 11 negative attitudes. Health workers have often treated women rudely. In one of the studies, women who had poor treatment by health workers during antenatal period were discouraged from delivering at a health unit (Lowry, et al., 2005). 2.5 Upgrading Skills for better service Mintz et al., (2000) stated that in many settings, improving services that already exist, investing in upgrading the skills and competence of health care providers and enhancing referral system can have significant impact on maternal health service delivery. In order to manage obstetric complications, a facility must have trained staff and a functional operating theatre, equipment for blood transfusion and anaesthesia. District hospital and health centers can often become capable of providing ANC by making few changes to their existing resources: renovating an existing structure, re-allocating rooms in the facility; regaining or purchasing medical equipment; converting unused facilities within the hospitals or health center into ANC unit, providing in-service training for service providers, develop protocols for ANC care; and standards for quality care and providing special training for maternity care providers (Mulu and Tilahu, 2009). According to United Nations Fund for Population Activities (UNFPA) Report, the key problems to antenatal care and delivery in Jamaica include staff shortages (with vacancy rates for midwives from 45% - 70%) inconsistent supply of essential items and client dissatisfaction with long waiting times. The problems all relate to weak institutional capacity. The report further said among the many barriers to Malawian women’s access to health care service are lack of information, poor interests in or disapproval of services, University of Ghana http://ugspace.ug.edu.gh 12 financial constraints, transportation and discomfort with male service providers (UNFPA, 2005). Maternal deaths could be prevented if women had access to quality health services during pregnancy, delivery and the post-partum period (UNFPA, 2004). Information collected from a strategy development tool identified a variety of problems related to unskilled delivery attendants, low skilled levels of staff in obstetric skills, health workers lack sensitivity to the needs and cultural practices of women; inadequate supervision, monitoring and evaluation systems; limited space, equipment and supplies in hospitals (UNFPA, 2004). The safe motherhood protocols refer to skilled care as supervised deliveries attended by a doctor or trained midwife. Uganda’s policy on training reflects the Uganda’s MOH priority on skilled attendance to pregnant women during pregnancy, delivery and postnatal care. The Ministry of Health also mandates regular in-service training as part of continuing education for promotion (WHO 2001). In Nepal, three months of basic training plus six weeks, of refresher training is provided for maternal and child health workers who serve as skilled attendants at the sub-health post level (WHO, 2007). 2.6 Benefits of quality ANC process The antenatal period represents an important opportunity for providing pregnant women with interventions that may be vital to their health and well-being and that of their infants (Mohammed, 2004). WHO indicate that in developing countries, ANC also reduces maternal mortality and preventive morbidity through early detection and treatments of pregnancy related or inter-current illnesses (malaria, anemia and syphilis) which are prevalent and have an University of Ghana http://ugspace.ug.edu.gh 13 impact on maternal and neonatal health. Malaria in pregnancy increases the chance of maternal anemia, abortion, stillbirth, prematurity, intrauterine growth retardation and infant low birth weight (WHO, 2008). It is estimated that as many as 30% of deaths during pregnancy in Africa directly result from malaria infection and malarial anaemia, and is estimated to cause as many as 10,000 maternal deaths each year in Africa (WHO, 2008). The burden of Malaria in pregnancy could be minimized by use of “Intermittent Presumptive Treatment” (IPT) and strengthening early detection and prompt treatment of cases among pregnant women. Establishment of minimum standards assures at the least a quality of service at the sub-district. Treatment of syphilis during pregnancy is another intervention which has proven to be effective in reducing perinatal mortality. Maternal-fetal transmission of syphilis during pregnancy may be as high as 80% and syphilis testing and treatment during antenatal period has proven to prevent stillbirths in most women (Holtzth et al., 2004). In addition, Bennet, (2004) revealed that globally, tetanus infections cause about 30,000 maternal deaths each year. Therefore tetanus immunization during pregnancy can be life saving to a mother. In countries where abortion is legal, early contact of a pregnant woman with the health system during antenatal period, allows women with unwanted pregnancies to be referred for safe abortion services (Murray and Lopez, 1997). Abortions contribute to 13% of maternal deaths in developing countries (UNFPA, 2006). More recently, the antenatal period act as an entry point for Human Immunodeficiency Virus (HIV) prevention and care. Most complications of both early and late pregnancy occur more often in women infected with HIV (Mclntyre, 2002). Examples of HIV related complications in HIV positive pregnant women are spontaneous abortion, ectopic University of Ghana http://ugspace.ug.edu.gh 14 pregnancy, preterm labor, and postpartum infections. HIV positive women access care (getting antiretroviral drugs, nutritional counseling and counseling) and support to prevent the complications during antenatal period. Furthermore, services on Prevention of Mother-to-Child Transmission (PMTCT) of HIV are offered during antenatal period. Mother-to-Child Transmission of HIV (MTCT) is by far the largest source of HIV infection in children below the age of five years (Carroli, 2001). However, other studies have indicated that some elements of ANC such as routine monitoring of height and weight gain may not be efficient to identify those most in need for obstetric service (Villar and Bergsjg, 2001). The low predictability of antenatal markers for adverse maternal outcomes has led some to reject antenatal care as an efficient strategy in the fight against maternal mortality (Vanneste et al., 2003). This has created a big gap in an effort to reduce MMR in most developing countries, as concentration on ANC is minimal (AbuBakar, et al., 2006). 2.7 Focused Antenatal Care Ghana has adapted the new World Health Organization (WHO) recommended new antenatal care package known as “Focused Antenatal Care” (FANC). The new model emphasizes on actions known to be effective in improving maternal or neonatal health, excluding other interventions that have not proved to be beneficial. The major goal of FANC is to help women maintain normal pregnancies through identification of pre- existing health conditions that may affect outcome of pregnancies such as malaria, HIV, anemia, and other sexually transmitted infections. It also includes identification of heart disease, diabetes, malnutrition and tuberculosis, early detection and treatment of University of Ghana http://ugspace.ug.edu.gh 15 problems and complications of anemia, infection, vaginal bleeding and hypertensive disorders of pregnancy that may become life threatening if left untreated. FANC also encourages health promotion and disease prevention activities which include vital health care messages such as required antenatal visits, essential services, danger signs (how to recognize danger signs and where to get help) good nutrition, importance of rest, breastfeeding, family planning and risks of using tobacco, alcohol, local drugs and traditional remedies and birth preparedness. Complication readiness and planning for a skilled attendant at birth, clean and safe delivery, place of birth, how to get there, items for birth, potential blood donors, coping with emergencies newborn care and support during and after birth are also included in FANC (Villar and Bergsjg, 2001). In FANC, the activities are distributed within the recommendation of minimum of four targeted antenatal visits, scheduled at specific times in the pregnancy. First visit takes place before four months (16 weeks) or as early as possible during pregnancy. The early initiation of antenatal care is important to, identify, prevent and treat complications. Second visit takes place in the sixth or seventh month (24-28 weeks) and the third visit in the eight month (32 weeks) to continue screening and to further develop the individualized birth plan. Monitoring occurs during these visits. Fourth visit takes place in the ninth month (36 weeks) to monitor and update the individualized birth plan. More visits may be necessary depending on the woman's condition and needs. 2.8 Consequences of poor ANC practices Substandard care resulting from poor staff supervision, underpayment, overworking and inadequate staff training or lack of refresher courses to upgrade staff skills have been University of Ghana http://ugspace.ug.edu.gh 16 reported in some studies. A study in Masawingo in Zimbabwe revealed substandard care during antenatal period which resulted from lack of skills contributed to a significant proportion of maternal deaths (Fawcus, 1998). Similarly in Vietnam quality of antenatal care was affected by poor staff skills (Graham, et al., 2001). Analysis of the study is based on the conceptual and analytic framework developed by Donabedian in 1979 as cited by Boller et al, (2003). The framework uses three elements of quality (structure, process and outcome). Structure refers to the conditions under which care is provided. Structural attributes in this study will include; human resources (number, variety, qualification of professionals), material resources (infrastructure, equipment and supplies). The structures will be assessed by a checklist. Process refers to activities that constitute health care and interaction between client and care giver. Process in this study will include; antenatal coverage, time of first ANC visit and frequency of visits. Technical aspects will include; history taking, physical examination (general and systematic and blood pressure), and laboratory investigations (blood for VDRL, haemoglobin, and HIV, urine testing for albumin). Process quality will also look at treatment, prescription of prophylaxis, provision of health promotion messages (specifically on diet, breast feeding, delivery preparation, obstetric complications) and referral system (efficiency and reliability). Judgment of interpersonal quality will be based on factors such as the accommodation provided for the women, privacy during consultation, and interaction between the client and provider. The process dimension will be assessed using all the data collection tools that will be used in this study. Outcome quality according to Donabedian means changes (desirable or undesirable) in individuals and population that can be attributed to health care provided. University of Ghana http://ugspace.ug.edu.gh 17 2.9 Client’s perception of quality ANC Quality of ANC depends on how women attend, initiate antenatal visits at a health facility. According to UNICEF/WHO, (2006), about 70% of women worldwide had at least one antenatal visit with a skilled provider during pregnancy. Also, in a joint report published by WHO, UNICEF, UNFPA and World Bank in 2005, ANC coverage was extremely high in the industrialized countries, with 98% of women having at least one visit. In the developing world, antenatal care use was around 68%. The region of the world with the lowest levels of use was South Asia, where only 54% of pregnant women have at least one antenatal care visit. In the Middle East and North Africa, use of antenatal care was somewhat higher (65%). In sub-Saharan Africa, about 68% of women report at least one antenatal visit (Dyah and Rizal, 2002). UNICEF/WHO, (2006), further stated that in Latin America, Caribbean, Middle East and North Africa the majority of women attended ANC at least 4 times in one pregnancy and two thirds of these women attended ANC in the first trimester. However, in sub-Saharan Africa, most women attended antenatal care in the second trimester and a relatively substantial proportion attended only in the third trimester. Although women in sub- Saharan Africa make their first antenatal visit rather late in pregnancy, they nonetheless attended more than one visit. It has also been established that the quality of ANC care received by clients is lower than expected in Ghana (MOH and GHS, 2007 and Adanu, 2010). University of Ghana http://ugspace.ug.edu.gh 18 CHAPTER THREE METHODOLOGY 3.1 Type of Study This is a cross sectional study using quantitative, qualitative and observation methods of data collection. 3.2 Study Area The Nkwanta South District occupies the north-eastern part of the Volta Region (Figure 2). The district is bounded to the North by the Nkwanta North District, to the South by the Kadjebi District, to the East by the Republic of Togo and to the West by the Krachi East District. The former Nkwanta District was divided in 2008 into two districts. The capital of the former Nkwanta District remains as the capital of the new Nkwanta South District. According to the Nkwanta District Health Management Team (DHMT) report released in 2011. The population of the district is 111,983 based on the national 2000 population census. It is therefore estimated that, expected pregnancies for 2012 is 3091. Other characteristics include large household sizes, high illiteracy rate which is about 80% with high birth and fertility rate (GDHS, 2008). The district has twenty health facilities; two hospitals, two health centre, one mission clinic and fifteen Community- based Health Planning and Services (CHPS) compounds. The staff strength of the entire district is 168. This include six medical officers (two Ghanaian doctor and three Cuban medical Brigades at Nkwanta District Hospital and one Ghanaian doctor at St. Joseph’s Hospital), two pharmacist, one public health nurse, thirty-five staff nurses, forty-seven University of Ghana http://ugspace.ug.edu.gh 19 community health nurses, fifteen midwives and three disease control officers and about fifty-nine auxiliaries complementing efforts (DHMT, 2010). Most villages in the district are inaccessible by road, and the district capital, Nkwanta, is linked to the north and south by un-tarred roads that become impassable during the rainy season. Even though figures are not available to support the claim, most communities still need facilities like roads, schools, clinic, potable drinking water, electricity. All these have consequences for health service delivery (DHMT, 2010). The map of Nkwanta South District is as shown in Figure 2. Figure 2 Map of Nkwanta South District showing the locations of health facilities. University of Ghana http://ugspace.ug.edu.gh 20 3.3 Study Population The study population was all pregnant women between the ages of 15-49 years who were accessing ANC services in the twenty (20) health facilities in the Nkwanta South District within the period of 21st May to 29th June 2012. 3.3.1 Inclusion Criteria All pregnant women aged between 15 – 49 years attending ANC in the selected health facilities and who were not admitted or referred were included in the study. 3.4 Study Variables The dependent variable of this study is perceived quality of care. The independent variables were demographic characteristics of respondents, empathy, communication, competence and availability of resources. 3.5 Sample Size A maximum sample size of 278 pregnant women attending antenatal were interviewed with a structured questionnaire. This was inclusive of supposed 10% non-response rate. 3.5.1 Sample Size Calculation The minimum sample size required for the study was estimated to be 252 using the formula n= p (1-p)(Z_/d) 2 (Bekele, 2008) where n is the sample size, Z_ is the standard normal deviate, set at 1.96 (95% confidence level, d is the desired degree of accuracy (taken as 0.05) and p, is the estimate of the satisfaction rate among the target population (which was assumed to be 50% in the absence of a pre-existing estimate). Adjustment for a 10% rate of non-responses yielded a final sample size of 278. University of Ghana http://ugspace.ug.edu.gh 21 Using population size of 3091, 50% level of satisfaction from a similar study done in Ethiopia by Bekele (2008), 5% margin of error at 95% confidence level, the sample size was calculated as: N = {1.96*1.96[0.77(1-0.50)/(0.05*0.05)]} = 272.138944 3.6 Sampling Methods The study was conducted in six out of the 20 health facilities in the district. The two (2) hospitals were purposively selected because they serve as referral facilities to all the peripheral facilities in the district. Also the 2 health centres were purposively selected because they were the least staffed. Random sampling method was used to select 2 CHPS compounds from the 15 CHPS compounds in the district. The names of all CHPS compounds were written on pieces of paper and put in a container. Two CHPS compounds were randomly selected from the container. Two hundred and seventy eight (278) pregnant women were selected and interviewed using a structured questionnaire during ANC services. 3.7 Subject Selection To achieve the desired sample size for the study, the number of pregnant women selected from each centre was determined by a proportional allocation ratio method, i.e. the total number of women sampled from each centre was in accordance with the relative proportion of its weekly antenatal clinic’s population. Women in each centre were selected by systematic random sampling method during the antenatal clinic days until the estimated sample size for the centre was achieved. University of Ghana http://ugspace.ug.edu.gh 22 3.8 Training of Data Collectors One-day training was organized for the data collection team which comprised of twelve data collectors, two supervisors and a data manager. All the data collection tools were revised during this training session and a template for data entry and analysis was developed. 3.9 Data Collection Methods Quantitative, qualitative and observation techniques were used in data collection. The quantitative data was collected through a structured pre-tested questionnaire which was translated into “Potor Twi” (a local version of Twi language) to facilitate communication. The variables included were socio demographic characteristics, maternal and child health variables and satisfaction from the services available and attitude of health care staff. The questionnaire was piloted at Krontang Community Clinic. The questionnaire used was a standard checklist of antenatal care based on WHO protocol for antenatal care which was modified by Ghana Health Services (WHO, 2002 and GHS, 2004). The questionnaire contained 47 items comprising 10 segments which included the client’s background characteristics, time of initial visit, number of visits and waiting time. It also comprised of 6 dimensions of quality care and overall rating of care. The questionnaire sought information on the background of clients, the quality of care they received, how they rated care they received, their level of satisfaction with the care they received and whether they would recommend the health facilities to their friends and relatives who become pregnant. Some of the questions require “yes” or “no” answer. Others required clients to rate the dimensions of quality and satisfaction on a 4-point University of Ghana http://ugspace.ug.edu.gh 23 Likert scale. The responses were scale-ranked from “poor” to “very good” for the dimensions of quality (rated from 1 – 4 with 1 being the lowest and 4 as highest); and “not satisfied” to “very satisfied” for satisfaction (rated from 1 – 4 with 1 being the lowest and 4 as highest). Six teams of trained local data collectors coordinated by two supervisors in addition to the principal investigator were involved in the data collection. The trained interviewers through face-to-face interview administered structured questionnaire to selected participants who received ANC services and were ready to leave the health facility. A checklist adopted from Ghana Health Services Reproductive Health Standards on ANC was used to assess ANC facility infrastructure, supplies and equipment, skill of health care providers and their practices during ANC clinic. The checklist covered areas on infrastructure (privacy, sanitation, lighting, space, coaches and chairs), universal precautions, drugs and supplies, total number of staff at the antenatal clinic, interpersonal relationship, routine practice, laboratory investigations and health promotion activities. Part two of this same checklist was used to observe health care providers providing antenatal services during antenatal clinic. Qualitative data was collected through Focus Group Discussions (FGD). Four FGD sessions were held which covered issues on participants understanding of quality ANC, their perception about care providers’ attitude, importance of ANC attendance, factors that make them feel satisfied or dissatisfied, initiation and frequency, place of last delivery and perception on the quality of ANC services. Each FGD session comprised of 10 homogenous groups of women who have children below age 6 months. Aided by FGD guide, the FGD sessions were conducted in “Potor Twi” the local version of the Twi University of Ghana http://ugspace.ug.edu.gh 24 languages. The FGDs were facilitated by a trained moderator who spoke fluent “Potor Twi” and 2 note takers/recorders. Tape recorder was used for the proceedings of the discussion. Tape recording was done to ensure accurate data and to facilitate analysis. Each focus group discussion lasted for about one hour. Data from FGD was used to et detailed information on the antenatal services from the respondent’s point of view. 3.10 Data Management and Analysis Data was analyzed using a Statistical Package for Social Sciences (SPSS) version 16.0 for Windows. Data was cleaned by running frequencies of all the variables to check for incorrectly coded data. Incorrectly coded data was double checked with the raw data in the questionnaire and corrected. Data quality was validated using double entry. Associations between independent and a dependent variable were tested using Chi square test. The independent variables tested were: educational level, marital status, Occupation, religion and age. The independent variables were tested against one dependent variable which was perceived quality of care. The association between the independent and the dependent variables were tested to see what variables could influence the outcome. Odds ratios and confidence intervals were also computed. The raw data from the observations and FGD were analyzed using thematic analysis procedures. The following steps with some modifications were adapted to analyze the data. The audiotapes from the FGD were transcribed verbatim and comparison with written notes was done for completeness, accuracy and as a data quality assurance measure. Each typed transcript was checked against the audiotape by someone fluent in “Potor Twi” language before being translated into English. In order to verify the quality of translation, tapes were double transcribed. The written transcripts from each interview were read and key words and University of Ghana http://ugspace.ug.edu.gh 25 significant statements were highlighted. The identified themes and sub themes that emerged from each interview were reviewed by the researcher, and similar themes were grouped together. Significant statements for each theme were identified and triangulated into the Quantitative data to give in-depth analysis of the quality of ANC at Nkwanta South District. 3.11 Quality Control All the field assistants and supervisors were trained together thoroughly for 2 days. Supervisors followed the teams to the field to supervise all the data collection sessions to ensure that data was really collected from the participants. Administered questionnaire from the field were thoroughly checked for accuracy and completeness on daily basis. All data forms from the field were coded and entered immediately into the SPSS version 16.0. 3.12 Ethical Considerations Prior to the initiation of research activities, ethical clearance was granted by Ghana Health Services Ethical Review Committee. A written permission was obtained from the Volta Regional Health Directorate, Nkwanta South District Health Management Team and the six facilities involved in the study. Each study participant completed a consent form (in the language of their choice) before participation in the study. Each participant was reminded that participation was voluntary and the discussion would remain confidential. No information pertaining to participants identity was recorded. Data summaries only included descriptions of participants in aggregate form. Questionnaire was administered on one-on-one basis. The completed forms were kept under key and lock. University of Ghana http://ugspace.ug.edu.gh 26 FGD participants were given a cake of sunlight toilet soap and a small sachet of iodated salt in appreciation of their participation. This study does not provide any direct benefits to the participants. Similarly, it did not pose any risk to participants. However, it may help to improve the quality of antenatal services in the district. 3.13 Study Limitations The major limitations of this study were: 1. Inadequate literature and scanty information on quality ANC relevant to Nkwanta South District. 2. Inadequate funding which could otherwise extend the coverage of the study to more facilities in the district. 3. Since the community leaders were responsible for selecting lactating mothers for FGD sessions, there was the likelihood of bias in selecting participants who were closely associated with them. University of Ghana http://ugspace.ug.edu.gh 27 CHAPTER FOUR RESULTS 4.0 Introduction This chapter highlights the findings of the study to assess the quality of Antenatal Care (ANC) at public health facilities in the Nkwanta South district. A total of 278 pregnant women were interviewed. The results were analyzed and presented in tables as follows: 4.1 Response Rate by Facilities All the 278 respondents sampled for the quantitative study in the in the facilities were interviewed. Table 1: Survey response rate by facilities Facility Total women sampled % in sample Total sampled in all facilities 278 100% Nkwanta District Hospital 103 37.0 St. Joseph Hospital 75 27.0 Bonakye CHPS Zone 39 14.0 Kecheibi CHPS Zone 28 10.1 Tutukpeni Health Centre 22 7.9 Breweniase Health Centre 11 4.0 Total interviewed in all facilities 278 100% Source: field questionnaire, 2012 University of Ghana http://ugspace.ug.edu.gh 28 There were three categories of health facilities studied. As shown in table 1, majority of the respondents (64%) were from the 2 hospitals, (24%) from the CHPS compounds and (11.9%) were from the health centers. All participants sampled for FGD (10 women each with children less than 6 months) from Odomi, Dadiese, Dogoketewa and Alhaji Bankyi Zongo participated in the study. 4.2 Demographic Characteristics of the Respondents Among the women interviewed with structured questionnaire in the survey there were more adults (87.4%) than teenagers 12.6%, The majority (85.6%) were married, 13.7% single and 0.7% widowed. The majority (40.6%) of the respondents had no formal education while 31.1% of the respondents attended JSS/Middle School. Christianity (62.5%) was the dominant religion among respondents and farming 37.4% was the major occupation followed by trading 34.9%. Majority (66.5%) of the pregnant women in the survey had been pregnant before and 33.5% were carrying their first pregnancy. A total of 40 participants from 4 communities participated in the FGD sessions. The participants were community women with children less than 6 months of age. The age for participants ranged from 18 – 39 years with a mean of 26.5 years. Nearly 96% of the participants from all the four communities were married, and almost all reported being farmers. Majority (64.3%) of the women had delivered at home. The study showed that only three out of the 40 women attended school up to the Junior High School level and four stopped at primary school. University of Ghana http://ugspace.ug.edu.gh 29 Table 2: Socio-demographic characteristics of the respondents (N=278) Variables Respondents N=278 Percentage (%) Age (years) 15-19 35 12.6 20-24 67 24.1 25-29 78 28.1 30-34 57 20.5 35-39 36 12.9 40-44 5 1.8 Highest level of education No formal education 113 40.6 Primary 67 24.1 JSS/Middle School 92 31.1 SSS/Secondary 6 2.2 Religion Christian 174 62.6 Muslim 58 20.9 Traditionalist 43 15.5 No religion 3 1.1 Marital Status Married 238 85.6 Single 38 13.7 Widow 2 0.7 Occupation Farmer 104 37.4 Trader 97 34.9 Student/Apprentice /Unemployed 56 20.3 Self-employed (Trades person) 15 5.4 Government employee 6 2.2 Source: field questionnaire, 2012 University of Ghana http://ugspace.ug.edu.gh 30 4.3 Structural resources available at the health facilities The checklist revealed that in the six facilities studied, a total of 32 health workers with varying designations were responsible for ANC activities. The checklist further revealed that the heads of the facilities sampled were responsible for overall administration of the respective facilities. The two hospitals had a system where the midwives at the ANC exchanged shifts, whereas the nurses at the CHPS compounds and health centres remain at post for 24-hours. General infrastructure for antenatal services was rated as “very good” (86.7%) at Nkwanta District Hospital while St. Joseph’s Hospital was rated as “good” (73.2%). Tutukpeni Health Centre and Kecheibi CHPS compound were rated “fair” 40.3% and 46.8% respectively. Breweniase Health Centre and Bonakye CHPS compound were rated “poor” 24.8% and 22.4% respectively. Infection prevention measures taken by the health care providers in the facilities were also rated on a Likert-scale of poor (1% - 25%), fair (26% – 50%), good (51%- 75%) and very good (76% - 100%). Nkwanta District Hospital and St. Joseph’s Hospital were rated as very good (81.2% and 78.3%) respectively; Kecheibi CHPS compound was rated good (64.5%); Breweniase and Tutukpeni health centres were rated 42.2%, 39.8%, & 37.8% respectively while Bonakye CHPS compound was rated 23.6%. Availability of supplies for disinfection such as sterilization, hand sanitizers, alcohol/spirit swabs, gloves and hand washing equipment, posters and evidence (list or guidelines) for preparation of disinfectants were also rated on a Likert-scale of “poor”, “fair”, “good” and “very good”. Nkwanta District Hospital was rated very good 78.4%, Kecheibi CHPS compound and St. Joseph’s hospital were rated good 64.3%, & 62.1% respectively while Bonakye CHPS University of Ghana http://ugspace.ug.edu.gh 31 compound, Breweniase and Tutukpeni Health Centres were rated 39.6%, 36.5% & 29.4% respectively. Availability of drugs such as anticonvulsant, magnesium-sulphate, anti-malarial drugs, vitamins and tetanus immunization, Nkwanta District Hospital and St. Joseph Hospital were rated very good with scores between (76% - 100%). Bonakye and Kecheibi CHPS compounds were rated fair with scores between (26% - 50%). Breweniase and Tutukpeni Health Centres were rated poor with scores between (1% - 25%). In addition, cleanliness and sanitation of the facility and items used such as bed sheets were rated on a Likert-scale of “poor”, “fair”, “good” and “very good”. Nkwanta District Hospital and St. Joseph’s Hospital were rated very good with scores between (76% - 100%), Kecheibi CHPS compound was rated good with scores between (51% - 75%) while Bonakye CHPS compound, Breweniase and Tutukpeni Health Centres were rated fair with scores between (26% - 50%). One woman during the FGD had this to say in response to type of facility and availability of resources: “The cities are endowed with good and modern equipment. The equipment in our facilities are not up to the required standard”. University of Ghana http://ugspace.ug.edu.gh 32 Table 3: General Infrastructure Rating for Antenatal Services Facility Rating % Score Nkwanta District Hospital Very Good 86.7 St. Joseph Hospital Good 73.2 Bonakye CHPS Zone Poor 40.3 Kecheibi CHPS Zone Fair 46.8 Tutukpeni Health Centre Fair 24.8 Breweniase Health Centre Poor 22.4 Infection Prevention and Control Practices Nkwanta District Hospital Very Good 81.2 St. Joseph Hospital Very Good 78.3 Bonakye CHPS Zone Poor 23.6 Kecheibi CHPS Zone Good 64.5 Tutukpeni Health Centre Fair 37.8 Breweniase Health Centre Fair 42.2 Availability of Infection Prevention and Control Supplies Nkwanta District Hospital Very Good 78.4 St. Joseph Hospital Good 64.3 Bonakye CHPS Zone Fair 39.6 Kecheibi CHPS Zone Good 62.1 Tutukpeni Health Centre Fair 29.4 Breweniase Health Centre Fair 36.8 Source: field questionnaire, 2012 University of Ghana http://ugspace.ug.edu.gh 33 4.4 Assessment of quality perspective dimensions (provider skills and practices) The qualities of the health service provision in this study were grouped into six dimensions namely; empathy, communication, competence, resource availability, tangibles and responsiveness. The effects of these qualities were assessed in respect of clients’ background characteristics. 4.4.1 Empathy All respondents (100%) in age group 40 – 44 years asserted positively to readiness of the staff to listen to clients‟ problems while in age group 20 – 24, 85.1% asserted; in age group 25 – 29, 84.6% asserted while 82.5% of those in age group 30-34 asserted. Among those in age group 15 – 19, 77.8% agreed whiles 63.8% of those in age group 35 – 39 also agreed. There was no significant effect of clients’ age on readiness of staffs to listen to clients‟ problems as all ages received equal listening to their problems from health care providers ( 2= 20.304; df =15, p= 0.161). All respondents (100%) in age group 40-44 years indicated that the health care providers had a caring attitude towards clients while 98.2% of those in 20-24 age group agreed. In age group 30-34 years, 89.5% consented that staff had caring attitude for clients. Seventy-eight percent of those in age group 25 – 29 years said, they had caring attitude from providers, while those in age group 15 – 19 years agreed on the same issue. Among age group 35 – 39 years 58.3% consented that they had caring attitude from the staff. There was a significant effect of clients’ age on staffs’ caring attitude since all age groups received different caring attitude ( 2= 41.438; df =15, p < 0.05). University of Ghana http://ugspace.ug.edu.gh 34 Table 4: Empathy offered by providers to clients Empathy Indicators Number of Clients with positive assessment by clients’ age groups No % 2 df P-value Staffs’ readiness to listen to clients’ problems 15 – 19 (N=35) 28 77.8 20.304 15 0.161 20 – 24 (N=67) 57 85.1 25 – 29 (N=78) 66 84.6 30 – 34 (N=57) 47 82.5 35 – 39 (N=36) 23 63.8 40 – 44 (N=5) 5 100 Staffs’ caring attitude 15 – 19 (N=35) 28 77.8 41.438 15 0.000 20 – 24 (N=67) 56 98.2 25 – 29 (N=78) 61 78.2 30 – 34 (N=57) 51 89.5 35 – 39 (N=36) 21 58.3 40 – 44 (N=5) 5 100 Source: field questionnaire, 2012 4.4.2 Communication Communication between care providers and clients were assessed and presented in Table 4. The results show that communication was provider initiated, telling clients their diagnosis, explanation on treatment to clients’, instructions to clients on what to do next and whether clients were getting “clear” information on other antenatal procedures. The distribution of provider-initiated communication regarding diagnosis is recorded in table 4 as follows; senior secondary education 66.7%, junior secondary/middle school group 58.1%, primary education 53.7%, and those without formal education 46.4%. There was no significant effect of clients’ education on staffs’ giving of information on clients diagnosis ( 2= 3.844; df =3, p= 0.279). The result also showed that among respondents with senior secondary education 67.7% were of the opinion that staffs‟ explanation on treatment to clients was adequate; University of Ghana http://ugspace.ug.edu.gh 35 respondents with primary education 58.2% agreed, among the junior secondary/middle school 52.1% agreed. Among those without formal education 45.5% said staffs’ explanation met their expectations. Thus, there was no significant effect of clients’ educational level on staffs’ explanation of their situation as pregnant women ( 2= 3.590; df =3, p= 0.279). The result further showed that among respondents with senior secondary education 66.7% said providers offered “clear” instructions on what to do next for clients, among respondents with primary education 59.7%, said they had “clear” instructions on what to do nest from providers while among those with junior high/middle school 54.3% affirmed they had “clear” instructions and those without formal education 42.8% also affirmed on the same issue. Consequently, there was no significant effect of clients’ educational level on staffs’ instructions on what to do next ( 2= 8.193; df =6, p= 0.188). It was noted that all respondents with senior secondary education (100%) were of the view that clarity of information given to clients by providers was adequate; those without formal education 88.4% agreed. Respondents with junior/middle school education 83.6% also consented that clarity of information given to clients was adequate; those with primary education 79.1% also agreed. It is therefore evident that clients educational level has a significant effect on clarity of information given to clients ( 2= 29.848; df = 9, p < 0.05). 4.4.2.1. Information Adequacy The results indicate that respondents without formal education 82.1% and those with primary education 82.1% were of the view that, providers offering of other services information to clients were adequate while those with junior secondary/middle 70.7% and University of Ghana http://ugspace.ug.edu.gh 36 those with senior secondary school 66.7% agreed respectively. Thus, there was a significant effect of clients’ educational level on provider offering other services information ( 2= 30.041; df =9, p < 0.05). Description of how participants felt during their visit to ANC with their last pregnancy at the FGD sessions. Majority of the respondents felt they were treated well by the health care providers; however others also felt they were taken advantage off by taking unofficial monies from them. Those who felt they were cheated explained that, though antenatal services were supposed to be free, health care providers insisted they go for National Health Insurance cards before accessing services. Those without the NHI cards were asked to pay for services. “I felt very relieved when I visited the ANC the first time with my last pregnancy. The nurse treated me very well. That encouraged me to be going there regularly until my last visit before delivery when the new nurse told me my NHI card expired so I should go to the NHIS office to renew it before I could be attended to. That day, „I cursed my star‟. The nurse was so rude towards me that I left the facility and went to another facility. For me so long as that nurse remains at that facility, I shall never go there again for services” (woman, Alhaji Bankyi Zongo). “You see, women become difficult especially when they become pregnant, that notwithstanding, pregnancy is a special period and pregnant women need to be handled with special care. I felt good when the doctor (male health care provider) talked to me politely. But as for the nurse (female health care provider) she is so rude and disrespectful. Therefore, I wait until the „doctor‟ is there before I go, when the nurse alone is around, I do not go there at all” (woman, Dogoketewa). University of Ghana http://ugspace.ug.edu.gh 37 Table 5: Communication between clients and providers Communication Indicators Number of Clients with positive assessment No % 2 df P-value Provider telling client the diagnosis No school (N=112) 52 46.4 3.844 3 0.279 Primary (N=67) 36 53.7 JHS/Middle (N=92) 54 58.7 Secondary (N=6) 4 66.7 Provider explaining treatment to clients No school (N=112) 51 45.5 3.590 3 0.309 Primary (N=67) 39 58.2 JHS/Middle (N=92) 44 52.1 Secondary (N=6) 4 66.7 Provider offering clear instructions on what to do next No school (N=112) 48 42.8 8.193 6 0.188 Primary (N=67) 40 59.7 JHS/Middle (N=92) 50 54.3 Secondary (N=6) 4 66.7 Clarity of information given to clients No school (N=112) 99 88.4 29.848 9 0.000 Primary (N=67) 53 79.1 JHS/Middle (N=92) 77 83.6 Secondary (N=6) 6 100 Provider offering other services information to clients No school (N=112) 92 82.1 30.041 9 0.000 Primary (N=67) 55 82.1 JHS/Middle (N=92) 65 70.7 Secondary (N=6) 4 66.7 Source: field questionnaire, 2012 4.4.3 Competence of Providers The competences of health care providers’ were assessed by the clients and the results are presented in Table 5. The results indicate that respondents without formal education 90.2% were of the opinion that, examining of clients by providers was adequate, respondents with junior secondary/middle school education 90.2% also agreed on the issue while those with primary education 77.6% and senior secondary education 66.7% agreed respectively. Thus, there was a significant effect of clients’ education on providers’ examination ( 2= 9.016; df = 3, p < 0.05). University of Ghana http://ugspace.ug.edu.gh 38 The results also show that, all respondent with senior secondary education (100%) agreed that the health care providers’ skills met their expectations. Respondents without formal education 97.3% shared the same view and those with junior secondary/middle school 94.6% also shared the view while those with primary education 89.6% consented that providers’ skills were adequate. There was no significant effect of clients’ educational level on adequacy of providers’ skills ( 2= 4.126; df = 3, p = 0.248). Table 6: Competence of providers as perceived by clients Competence Indicators Number of Clients with positive assessment by clients’ educational level No % 2 df P-value Provider examination of client No school (N=112) 101 90.2 9.016 3 0.029 Primary (N=67) 52 77.6 JHS/Middle (N=92) 83 90.2 Secondary (N=6) 4 66.7 Adequacy of providers’ skills No school (N=112) 109 97.3 4.126 3 0.248 Primary (N=67) 60 89.6 JHS/Middle (N=92) 87 94.6 Secondary (N=6) 6 100 Source: field questionnaire, 2012 4.4.4 Availability of some essential resources The result of the availability of some essential medicines in relation to clients’ educational level is presented in Table 6. All respondents with senior secondary education (100%) were of the view that providers‟ observing clients to take medication at ANC was adequate. About eighty-four percent (83.5%) of respondents with primary education agreed; 79.3% of respondents with junior secondary/middle school education agreed while those without formal education 72.3% also agreed. There was no significant effect of clients’ educational level attained on providers observation of clients taking medication at the ANC centre ( 2= 5.566; df =3, p= 0.135). University of Ghana http://ugspace.ug.edu.gh 39 All respondents with senior secondary education (100%) were of the opinion that clients‟ understanding of medication instructions offered by providers was adequate. Eighty-five percent of those with primary education agreed; eighty-five percent (84.7%) of respondents with junior secondary/middle school education agreed, while those without formal education 75.8% also agreed. There was no significant effect of clients’ educational level on clients’ understanding of medication instruction ( 2= 5.487; df =3, p= 0.139). Fifty (50.0%) of the clients with senior secondary education were given prescription to buy medication outside of the antenatal clinic while 35.8 of those with primary education had prescription forms. Thirty-two percent (31.5%) of those with junior secondary/middle school had prescription forms and only (8.0%) of respondents without formal education said they were given prescriptions to buy some medication outside the facility. There was a significant effect of clients’ educational level on providers giving prescription for medicines to be bought outside the Antenatal clinic ( 2= 26.556; df =3, p < 0.05). All clients with senior secondary education (100%) were of the view that, the medicines supplied by the health care provider for clients‟ condition were adequate as compared to 82.1% of those with primary education, sixty eight percent (68.5%) of the junior secondary/middle school education group and 40.1% of those without formal education. Hence, there was a significant effect of clients’ educational level on perception of adequacy of prescribed medication ( 2= 39.745; df =3, p < 0.05). University of Ghana http://ugspace.ug.edu.gh 40 Table 7: Availability of some essential services Competence Indicators Number of Clients with positive assessment by clients’ educational level No % 2 df P-value Provider observation of clients medication No school (N=112) 81 72.3 5.566 3 0.135 Primary (N=67) 56 83.5 JHS/Middle (N=92) 73 79.3 Secondary (N=6) 6 100 Clients’ understanding of instruction on medication No school (N=112) 85 75.8 5.487 3 0.139 Primary (N=67) 57 85.1 JHS/Middle (N=92) 78 84.7 Secondary (N=6) 6 100 Provider prescribing medicines for client No school (N=112) 9 8.0 26.556 3 0.000 Primary (N=67) 24 35.8 JHS/Middle (N=92) 29 31.5 Secondary (N=6) 3 50.0 Availability of prescribed drugs No school (N=112) 6 5.3 40.368 9 0.000 Primary (N=67) 17 25.3 JHS/Middle (N=92) 23 25.0 Secondary (N=6) 1 16.7 Adequacy of medicines prescribed No school (N=112) 45 40.1 39.745 3 0.000 Primary (N=67) 55 82.1 JHS/Middle (N=92) 63 68.5 Secondary (N=6) 6 100 Source: field questionnaire, 2012 4.4.5 Tangibles The cleanliness of the providers’ environment including staff appearance, availability of instruments and comfort of clients’ waiting area were assessed and presented in Table 7. Ninety-one percent of the respondents who were farmers said, the environs of the antenatal care facilities were clean. Among the student/apprentice/unemployed group, 89.0% said the facilities were clean. Among the traders 84.5% said facilities were clean, for the self employed group, 66.7% said facilities were clean; 66.7% of the government employees also said ANC facilities were clean. There was a significant effect of clients’ occupation on perception of facility’s cleanliness ( 2= 57.750; df = 12, p < 0.05). University of Ghana http://ugspace.ug.edu.gh 41 All the government employees (100%) rated the staffs as neat. Eighty-nine percent of the student/apprentice/unemployed said the staffs were neat. Among the traders, 88.7% said the staffs were neat. Of the farmers, 87.5% said staffs were neat. Again, clients’ occupation had a significant effect on perception of staffs’ neatness ( 2= 30.794; df = 12, p < 0.05). All clients who were student/apprentice/unemployed (100%) and government employees (100%) rated their providers‟ equipments as adequate. while 95.2% of the farmers were of the same view; 89.7% of the traders were also of this view while 86.6% of the self employed rated providers’ equipment as adequate. Thus, clients’ occupation did not have a significant effect on perception of providers’ equipments adequacy ( 2= 8.766; df = 12, p = 0.067). A comfortable waiting area was adequately provided for 89.0% of clients who were student/apprentice/unemployed while 87.5% of respondents who were farmers were also provided comfortable waiting area. Among the self-employed 80.0% said they were provided with comfortable waiting area; 76.3% of the respondents who were traders agreed to the same view while half (50.0%) of the government employees rated the comfort of waiting area as adequate. There was a significant effect of clients’ occupation on perception of comfort at facilities’ waiting area ( 2= 24.150; df = 12, p < 0.05). University of Ghana http://ugspace.ug.edu.gh 42 Table 8: Tangibles in health care providers’ settings Tangible Indicators Number of Clients with positive assessment by clients’ occupation No % 2 df P-value Cleanliness of the facility Farmer (N=104) 95 91.3 57.750 12 0.000 Trader (N=97) 82 84.5 ASU* (N=56) 50 89.0 Self employed (N=15) 10 66.7 Gov Employee (N=6) 4 66.7 Neatness of staff Farmer (N=104) 91 87.5 30.794 12 0.002 Trader (N=97) 86 88.7 ASU* (N=56) 50 89.0 Self employed (N=15) 10 66.7 Gov Employee (N=6) 6 100 Adequacy of equipment Farmer (N=104) 99 95.2 8.766 4 0.067 Trader (N=97) 87 89.7 ASU* (N=56) 56 100 Self employed (N=15) 13 86.6 Gov Employee (N=6) 6 100 Comfort of waiting area Farmer (N=104) 91 87.5 24.150 12 0.019 Trader (N=97) 74 76.3 ASU* (N=56) 50 89.0 Self employed (N=15) 12 80.0 Gov Employee (N=6) 3 50.0 Source: field questionnaire, 2012 (* apprentice/student/unemployed) 4.4.6 Responsiveness The clients’ assessment of health care providers’ level of responsiveness to clients’ psycho-physiological needs in relation to their marital status is presented in Table 8. The waiting time spent by the client before they were attended to by the health care provider was rated as “good” by 74.4% of married clients, 60.5% by single clients while none of the widowed clients responded. There was a significant effect of clients’ marital status on perception of clients’ waiting time ( 2= 39.942; df = 6, p < 0.05). All widowed clients (100%) said they were respected by the health care providers while 87.8% of the married clients and 68.4% single clients rated respect from providers’ University of Ghana http://ugspace.ug.edu.gh 43 adequate. Marital status therefore had a significant effect on clients’ reception of respect from staffs ( 2= 21.888; df = 6, p < 0.05). Respect for privacy during physical examination was rated as adequate by 91.2% of the married clients while 65.8% of the single clients rated privacy during physical examination as adequate. There was a significant effect of clients’ marital status on level of respect for privacy received during physical examination ( 2= 199.901; df = 6, p < 0.05). Enough time for questioning during care was rated as adequate by all widowed clients (100%) while 84.3% of the married clients agreed and 71.1% of the single clients were of the opinion that enough time was given for asking questions . Thus, clients’ marital status had a significant effect on allotted time to ask questions at antenatal clinics ( 2= 17.717; df = 6, p < 0.05). According to the results all widowed clients (100%) were involved in the decision making process concerning their antenatal health care service needs while 91.6% of the married clients and 81.1% of the single clients were involved. Consequently, marital status was again found to significantly affect the level of client’s involvement in their antenatal health care needs ( 2= 12.200; df = 6, p < 0.05). Respect for privacy during verbal communication was rated as “good” by (91.6%) married clients while (76.3%) of the single clients and half (50.0%) of the widowed client shared the same view. Hence, there was a significant effect of clients’ marital status on level of privacy received during verbal communications ( 2= 52.405; df = 6, p < 0.05). All widowed clients (100%), 87.0% of married clients and 71.1% of single clients rated the way personal information was kept confidential as “good”, In effect, marital status University of Ghana http://ugspace.ug.edu.gh 44 did not have a significant effect on the level of client’s right of confidentiality by the providers ( 2= 8.881; df = 6, p = 0.180). Table 9: Responsiveness of providers to clients’ needs Responsiveness Indicators Number of Clients with positive assessment by clients’ Marital status No % 2 df P-value Waiting time Married N=238 177 74.4 39.942 6 0.000 Single N=38 23 60.5 widowed N=2 0 0.0 Respectfulness of client Married N=238 209 87.8 21.888 6 0.001 Single N=38 26 68.4 widowed N=2 2 100 Privacy during examination Married N=238 217 87.8 199.901 6 0.000 Single N=38 25 68.4 widowed N=2 0 0.0 Time given for clients to ask questions Married N=238 200 84.3 17.717 6 0.007 Single N=38 27 71.1 widowed N=2 2 100 Involving clients in decision making Married N=238 218 91.6 12.200 6 0.058 Single N=38 31 81.6 widowed N=2 2 2 Ensuring clients privacy in communication Married N=238 218 91.6 52.405 6 0.000 Single N=38 29 76.3 widowed N=2 1 50.0 Confidentiality Married N=238 207 87.0 8.881 6 0.180 Single N=38 27 71.1 widowed N=2 2 100 Source: field questionnaire, 2012 4.5 General Rating of Quality of care and Client Satisfaction The general overall rating of ANC quality was 93.6% by respondents visiting the antenatal clinics. Notwithstanding this perspective (6.1%) of the clients rated quality of University of Ghana http://ugspace.ug.edu.gh 45 care as poor. Some clients’ characteristics like age, educational level, marital status and provider’s skills, including respondents’ perceived staffs’ attitude affected the general view of quality among the pregnant women attending the antenatal facilities. 4.6 Multinomial logistic regression analysis Result in this section showed associations between the independent variables namely health providers’ characteristics, patients’ characteristics and health care systems characteristics and the dependent variables perceived quality of care. 4.6.1 Multinomial logistic regression of patients’ characteristics and providers’ skills and practices Significant Positive Associations:  Client’s occupational status was positively associated with the provider’s tendency to communicate what was wrong with clients. As observed, unemployed clients were 1.0 time more likely in a better position to assess fully what their diagnosis were from the providers than the other clients with different occupations.  Clients’ religious affiliation had a positive relationship with the provider’s giving drugs to be taken under observation at the antenatal clinic. Christians forming the majority enjoyed taking drugs under the supervision of health staffs.  Client’s educational status was positively associated with client’s opinion about adequate equipment for antenatal clinic services. Clients with senior secondary education were 0.4 times less likely to rate providers’ equipments and resources University of Ghana http://ugspace.ug.edu.gh 46 as inadequate as the other educational levels. In this same respect, client’s occupational status was positively associated with client’s opinion about adequate equipment for antenatal clinic services. Unemployed clients were 1.8 times more likely to rate their facilities’ equipments more adequate than the other respective occupations.  Client’s educational status was positively associated with generally how clients felt satisfied about antenatal clinic services. Those with senior secondary school education were 0.7 times less likely to perceive generally their antenatal care as unsatisfying. Significant Negative Associations:  Client’s educational status was negatively associated with the readiness of staff to listen to their problems. Those with no formal educational level were 0.6 times less likely to communicate effectively with ANC staff to be well listen to. Higher education therefore aided clarity of client-provider communication. ANC services participants considered more important during FGD sessions All respondents from the different communities considered the safety of their unborn babies (fetus) as the one most important reason for attending ANC. Very few considered the education they received from the health care providers as most important. Their responses reflected in some of the quotes from the FGD sessions. Women from all the communities also mentioned ANC was important in the case of prenatal complications. “The most important thing at the ANC is to be sure the fetus is in good health” (woman, Dogoketewa). University of Ghana http://ugspace.ug.edu.gh 47 Table 10: Logistic regression of patients’ characteristics and providers’ skills and practices Patient Characteristics Provider’s Characteristics Readiness of staff to listen to clients’ problems Odds Ratio 95% C.I p-value Client’s Educational Level 0.599 0.425, 0.843 0.003 Telling clients what was wrong with them Client’s Occupation 1.270 1.053, 1.533 0.012 Clients given drugs to take under observation at ANC Client’s Religious Affiliation 1.582 1.014, 2.468 0.043 Adequate equipment for ANC Services Client’s Educational Level 0.412 0.193, 0.876 0.021 Client’s Occupation 1.817 1.099, 3.001 0.020 Clients satisfaction about ANC services in the facilities Client’s Educational Level 0.732 0.572, 0.939 0.014 Source: field questionnaire, 2012 4.6.2 Multinomial logistic regression of clients’ perception of satisfaction and quality of care Clients’ perception of quality was influenced by their perception of service satisfaction by providers. Significant Positive Associations:  Pregnant women who were cared for properly as clients were 6 times more likely to be very satisfied about antenatal care than the rest. University of Ghana http://ugspace.ug.edu.gh 48  Perception of satisfaction was also positively associated to adequate drug prescription by providers. However, clients who bought drugs outside the providers’ facility were 0.6 times less likely to be satisfied with services. Significant Negative Associations:  Informing clients’ about what was wrong with them had a negative association with clients’ perception of satisfaction of care. Hence, clients who were informed adequately about what was wrong with them were 0.1 times less likely to be dissatisfied with providers’ services.  Provider’s information on what to do next by clients similarly had a negative association with clients’ perceived satisfaction. In effect, pregnant women who were given periodic information on what to do next were 0.4 times less likely to perceive dissatisfaction with providers’ services. In all, antenatal clients’ view of satisfaction was positively associated with antenatal clients’ rating of quality care and service. Hence, pregnant women who perceived satisfaction of antenatal care were 26 times more likely to perceive quality antenatal care than clients who do not. During the FGD session participants described satisfaction as inherent and subjective depending on situations in which one finds herself in. Consequently, several definitions were allotted for satisfaction in ANC. This was how a woman defined satisfaction. ”As for me satisfaction is when my health problems are solved at the facility. When I am sick and go to the hospital and the health care providers give me medication and I am University of Ghana http://ugspace.ug.edu.gh 49 healed, I am satisfied, and I think this is the reason why anybody would go to the hospital in the first place” (woman, Odomi). Table 11: Clients’ perception of satisfaction and quality of care Provider’s service Satisfaction and Quality of Care Clients satisfaction about ANC services in the facilities Odds Ratio 95% C.I p-value Caring about pregnant women as client 6.993 3.534, 13.836 0.000 Informing Clients’ about Diagnosis 0.114 0.39, 0.335 0.000 Provider’s Information on what to do next 0.428 0.232, .791 0.007 Prescribing medicine to be bought outside clinic 0.056 0.025, 0.129 0.000 Clients rating of quality of care at ANC Perception of General Satisfaction 26.774 11.324, 63.304 0.000 Source: field questionnaire, 2012 What quality of antenatal care meant to participants Similar themes were found at all the four FGD sessions. The knowledge exhibited by participants was found to be closely linked to the activities performed at the ANC. However, majority of them were skeptical about defining quality ANC. In the areas where ANC activities were vibrant, such as Nkwanta where the two (2) major hospitals are located, the knowledge about quality ANC seemed to be high. This was how a woman at Alhaji Bankyi Zongo summarized quality ANC. University of Ghana http://ugspace.ug.edu.gh 50 “We cannot tell which care is quality because we believe the nurses and the doctors are trained to provide care that is adequate for the pregnant woman and the growing fetus. Therefore whatever care they provide to us is assumed to be of the highest quality available. We cannot compare any of our facilities here (in this district) to facilities in Accra or any other big cities. For me, all the health care providers undergo the same kind of training however, equipment at the facilities differ. The cities are endowed with good and modern equipment. The equipment in our facilities are not up to the required standard. If our health care providers are given the required equipment, some can even perform better than those in the big cities” (woman, Alhaji Bankyi Zongo) University of Ghana http://ugspace.ug.edu.gh 51 CHAPTER FIVE DISCUSSIONS 5.0 Introduction This study described the assessment of quality of Antenatal care services in selected facilities in the Nkwanta South District and how these findings relate to the results of previous studies. The study was limited to the perceptions of clients in selected health facilities during the study period. It described the type of health facility, demographic characteristics and their relationship with provider and nature of health care received. It also showed the resource capacity of the facilities, perception of the clients as related to the nature of quality care and the general perception of satisfaction which may lead to overall quality of care. The study showed again, the quality gaps that need to be filled in order to meet the expectations of the client. 5.1 Type of Facility and Resources Available The descriptive analysis showed that (64%) of the clients sampled attended the two hospitals out of the six (6) health facilities. All antenatal facilities were supposed to provide some level of quality care in order to satisfy clients’ needs. But the results showed some variations in facility resources, health care providers’ skills and practices and client characteristics were factors for pregnant women in choosing which facility to attend. The findings further show that Nkwanta South District had adequate number of skilled personnel to attend to pregnant women at the antenatal clinics. The number of staff was adequate compared to the number of women reporting for ANC per day and considering University of Ghana http://ugspace.ug.edu.gh 52 the required services and counseling provided. This is in contrast to other studies done in Ghana by Ghana Maternal Health Survey (GHMS) (2007) report, Ethiopia by Olijira and Gebre-Selassie (2001) and Malawi by Safe Motherhood project (2002) where low staff levels in most public health facilities to provide antenatal services were recorded. Lack of proper infrastructure for providing ANC was identified in the district. Antenatal women had to wait for long hours before being attended due to lack of proper structures. This finding concurs with another study in Istanbul by (Turan et al. 2004) where there were no proper structures for providing ANC in most public health facilities which hindered most women from reporting for ANC especially during rainy seasons. In addition, there were also inconsistent supplies of logistics for ANC. 5.2 Assessment of Quality Perspective (Providers’ Skills and Practices) The general qualities of the Health service providers as associated with clients’ characteristics are discussed under empathy, communication, competence, availability of resources, tangibles and responsiveness and presented as follows. 5.2.1 Empathy As a duty of all health care providers, staff ought to be ready to listen to clients in their efforts to be empathetic. As evident in this study, age did not have any influence on staffs’ readiness to listen to client (p= 0.161) as all ages received equally empathic listening staffs (Turhal et al, 2002). However, all (100%) respondents between 40-44 years pointed out that the staff had a caring attitude. Clients’ age served as a determinant for staffs’ caring attitude as all age groups perceived and experienced different levels of University of Ghana http://ugspace.ug.edu.gh 53 empathy from health care providers (p < 0.05). This finding is in line with GHMS (2007) survey report of some facilities being empathetic to their clients’ needs. 5.2.2 Communication The assessment on communication was rated good. Ratings based on their educational levels showed no significant difference in staffs’ giving of information about what was wrong with clients (p= 0.279), explanation of their situation as pregnant women (p= 0.279) and consequently, giving of instructions on what to do next (p= 0.188). Nonetheless, on the staffs’ clarity of communication (p < 0.05) and offering of other treatment information (p < 0.05), the educational levels of clients created some amount of differentiation as more than (80%) of clients with senior secondary school education understood and communicated with staff better than the rest with lower educational level. These findings are in contrast to Turhal et al (2002) who found a negative association between education and satisfaction. 5.3.3 Competence Clients’ perception of competence among providers was measured on respondents’ perception of sufficiency of health providers’ skills. All indicators were rated high by respondents. With respect to educational level of clients, over (90%) of clients’ with higher educational level consistently felt more comfortable with the staffs’ skills on physical examination during pregnancy (p < 0.05) than those with lower education. However, there was no difference in their perception about their providers’ perceived skill adequacy (p = 0.248). As a result, clients’ although may not be comfortable during University of Ghana http://ugspace.ug.edu.gh 54 providers’ examination, their perception about providers general competency level were rated equally by all clients as very good. 5.2.4 Availability of Resources The availability of some resources (e.g. anticoagulants, anti-malarial, vitamin tablets and tetanus immunization) was also rated as good by majority of the clients although complaints of lack of prescribed medicines were observed. This result was supported in some studies in Tanzania (AbuBakar, et al., 2006) and in Zimbabwe (Mathole, et al., 2005) where the lack of medicines were observed as a major challenge. Clients’ characteristics like education affected their view on prescriptions to be bought outside the antenatal clinic (p < 0.05) with those with senior secondary education being more likely to accept the idea of buying medicines from outside the facility. 5.2.5 Tangibles The cleanliness of the providers’ environment including staff appearance, availability of instruments and comfort of clients’ waiting area was rated averagely high among respondents. However, occupational status of clients created some perceptual differences about facilities cleanliness (p < 0.05), perception of staffs’ neatness (p < 0.05) and facilities’ waiting area comfort (p < 0.05) as the employed clients rated very high on these aspects. 5.2.6 Responsiveness The quality of waiting time was rated as quite adequate by more than half of the total respondents. Nonetheless, marital status of clients affected their perception of quality of waiting time before attended to (p < 0.05) and staffs’ respect for clients in verbal University of Ghana http://ugspace.ug.edu.gh 55 communication (p < 0.05). From this result, married pregnant women felt more of staffs’ responsiveness than the others. Privacy received during physical examination (p < 0.05), enough time for questions in antenatal clinic (p < 0.05), and level of client’s involvement in her antenatal health care (p < 0.05). In effect, married and widowed clients were rendered a good level of responsiveness than single clients (Bekele et al, 2008). 5.2.7 Overall Satisfaction and Quality As observed from the associations between clients’ characteristics and providers’ skills and practices, general satisfaction was high among all the clients. The model proposed fits into the conceptual frame that, perception of clients’ satisfaction after being influenced by clients’ personal characteristic and providers’ services. Negative attitudes of health providers (Lowry, Saeger & Barnett S, Safe Motherhood Project, 2002) and other factors like inadequate facility resources with some organizational challenges like long waiting time (Adamu & Salihu, 2002, Pembe et al., 2010), to have an effect on satisfaction. Service providers seem to influence clients’ perception of satisfaction based on their association with client’s personal characteristics. There was no association between clients’ satisfaction and age of the client (Turhal et al, 2002). The occupational status of the clients was positively associated with the provider’s tendency to communicate what was wrong with clients. Client’s occupational status was positively associated with client’s opinion about adequate equipment for antenatal clinic services. Unemployed clients perceived their facilities more adequate than the other respective occupations. Also, client’s educational status was positively associated with generally how clients felt satisfied about antenatal University of Ghana http://ugspace.ug.edu.gh 56 clinic services as Oljira and Gebre-Selassie (2001) while Turhal et al (2002) found no association between education and satisfaction. The model proposed fits into the conceptual framework that, the perception of clients’ satisfaction after being influenced by their own personal characteristic and providers’ skills and practices led to perceived quality antenatal care. Negative attitudes of health providers (Lowry, Saeger & Barnett, 1997, Safe Motherhood Project, 2002) and other factors like inadequate facility resources with some organizational challenges like long waiting time (Adamu & Salihu, 2002, Pembe et al., 2010) were noted to have a negative effect on overall clients’ satisfaction. More so, this relationship as moderated by facility’s resources creates a positive association with antenatal clients’ rating of quality care and service. Pregnant women who were satisfied with antenatal care services perceived the antenatal care provided in the Nkwanta district as very good quality. University of Ghana http://ugspace.ug.edu.gh 57 CHAPTER SIX CONCLUSION AND RECOMMENDATION 6.1 Conclusion This study shows that antenatal care services provided in the Nkwanta South district is in line with the national standard. There is therefore, some quality of antenatal care and client satisfaction in the six facilities. The study also shows that, generally, most of the respondents were satisfied with the services they received. The clients were satisfied with the six (6) dimensions of quality which include: empathy, competence, communication, resource availability, tangibles and responsiveness. However, respondents were not satisfied with structural resources and some aspects of responsiveness and communication such as long waiting time, limited time to ask questions, and erratic supply of some essential medicines especially among the health centres and CHPS compounds and this could affect the quality of care. University of Ghana http://ugspace.ug.edu.gh 58 6.2 Recommendations Based on the conclusions drawn from results, the following recommendations are necessary: 1. Communication can be improved if the staffs undergo in-service training in communication skills 2. Clients must be informed about what to do at every stage of service delivery. 3. Clients must be treated with respect and not underestimating their socio-cultural values. 4. Health facilities must regulate their schedules and staffs to work in a manner to reduce clients’ waiting time. 5. There is the need to support the hospitals, health centres and CHPS zones with quality assurance surveys, adequate supervisions and in-service trainings for staff to enhance providers’ skills and practices in service previsions. 6. Further studies on quality of focus antenatal care are required. University of Ghana http://ugspace.ug.edu.gh 59 REFERENCES Abu Bakar, S. & Jegasothy, R. A. (2006). “Strategy for reducing maternal mortality”. Bulletin of the World Health Organization, 77 (2), 190-193. AbouZahr, C. & Wardlaw T. (2003). Antenatal care in Developing countries. Promises, Achievements and Missed opportunities. Analysis of trends, levels and Differentials 1999-2000. WHO & UNICEF; [Accessed on 13 December, 2011]. Available from: http://www.who.int/reproductiveheallth.pdf, Adamu, Y. M. & Salihu, H. M. (2002). Barriers to the use of antenatal and obstetric care services in rural Kano: Nigeria. Journal of Obstetric and Gynecology, 22 (6), 600- 603. Adanu, M. R. (2010). 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Martins, J., Rajapaka, L., Craig, L., Selvaraju, A., et al. (2003). Maternal health: Learning from Malaysia and Sri-Lanka. Documents & Reports, 1 (1), 156-160) Pembe, B. A., Calstedt, A., Urassa, D. P., Lindmark, G., Lennarth, N. and Darj, E. (2010). Quality antenatal care in rural Tanzania: counseling on pregnancy and danger signs Retrieved April 2, 2012 from http://www.biomedcentral.com /1471-2393/10/35 Safe Motherhood Project (2002). Qualitative Needs Assessment Report. MOH, Accra University of Ghana http://ugspace.ug.edu.gh 62 Turhal, S. N., Basak, E., Mahmut, G., Mehmet, A., Ayla, K. and Meric, S. (2002). Biomed cancer centre. Patient satisfaction in the outpatients’ chemotherapy unit of Marmara University, Instabul, Turkey. Retrieved June 26, 2012, from http://www.biomedcentral.com/1471-2407/2/30 Turan, J., Bulut, A., Nalbant, H., Ortayh, A. and Akalin, H. (2004). The quality of Hospital based Antenatal care in Instabul. Family Planning. 2004; (1) 37. (UNFPA). (2004). The Cairo consensus at ten: Reproductive health and its global effort to end poverty. UNFPA, Cairo. UNFPA. (2005). The promise of equality: Gender equality, reproductive health & the MDGs. Journalist’s press kit (pp.2-3). UNFPA, Cairo. UNICEF, & WHO. (2006). Antenatal Care in Developing Countries. Promises, Achievements, and missed opportunities: an analysis of trends, levels and differentials, 1990–2001. Geneva. UINCEF, & WHO. (2008). Tracking progress in maternal, newborn & child survival. UNICEF, New York. UNFPA. (2006). 2006 Reproductive health and safe motherhood report. Retrieved April 8, 2012, from http://unfpa.org/public/home/publications/pid/40/ISBN 0-89714-812-6 Vanneste, A. M., Ronsmans, C., Charkraborty, J. and Francisco, A. D. (2003). Prenatal screening in rural Bangladesh: From prediction to care, health policy and planning (Vol. 15) United Kingdom: Oxford University Press Villar, J. & Bergsjg, P. (2001). Scientific basis for the content of routine antenatal care: Philosophy, recent studies, and power to eliminate or alleviate adverse maternal outcomes: Scientific basis for the content of routine antenatal care. Informa Healthcare 76 (1), 1-14 WHO. (2001). Antenatal care: Randomized trial for implementation of new model. WHO, Geneva WHO. (2007). Focused antenatal care: Providing integrated individualized care during pregnancy. Access, 175-181 University of Ghana http://ugspace.ug.edu.gh 63 WHO. (2006). The World Health Report 2006 - Working together for health. Retrieved June 1, 2012, from http://www.who.int/whr/2006/en/ WHO. (2007). The world health report2007. A safe future: Global public health security in the 21st century. WHO, Geneva WHO. (2008). WHO Statistical Information System. Retrieved June 2, 2012, from http:www://who.int/whosis/whostat/2008/en/index.html WHO, UNICEF, UNFPA and The World Bank: (2005) Maternal Mortality in 2005 Estimates developed by WHO, UNICEF, UNFPA and The World Bank [accessed 12 June 2012]; Available from: http://www.who.int/whosis/mme_2005.pdf University of Ghana http://ugspace.ug.edu.gh 64 APPENDICES Appendix 1 Consent form ASSESSING THE QUALITY OF ANTENATAL CARE IN NKWANTA SOUTH DISTRICT Informed Consent Form Department of Health, Policy, Planning and Management: School of Public Health, College of Health Sciences. Background My name is: ________________________________a student from the School of Public Health, university of Ghana, Legon. I am conducting a study on Assessing the quality of antenatal care in Nkwanta South District Procedures The study will involve answering questions from a questionnaire about Assessing the Quality of Antenatal Care Services in Nkwanta South District. There will be no invasive procedures to obtain sample from participants. It will be appreciated if you could participate in this study. This is purely academic research which forms part of my work for the award of a Masters Degree in Public Health. Risks and Benefits The procedures involved in this study are non invasive and will not cause any discomfort to the participants. The results of the study may be used to improve antenatal care in our facilities. University of Ghana http://ugspace.ug.edu.gh 65 Right to Refuse Participation in this study is voluntary and you can choose not to answer any individual question or all the questions. You are at liberty to withdraw from the study at anytime. However, I will encourage you to fully participate in the study since your opinions are important. Anonymity and Confidentiality You are assured that information provided on the questionnaire is strictly confidential and information submitted would not be shared with anybody who is not part of the study. Dissemination of Results The results of this study will be sent to you by post or e-mail if you provide your addresses below. Before taking Consent Do you have any questions you wish to ask about the study? Yes No (if yes, please, indicate the questions below) …………………………………………………………………………………………… If you have any questions later please, contact Degley, Joseph Kwami (Tel: 0244975062). Consent I ……………………………………….., declare that the purpose, procedures as well as risks and benefits of the study have been explained to me in the local dialect and I have understood. I hereby agreed to take part in the study: Signature of participant………………………………….Date:…………………………… University of Ghana http://ugspace.ug.edu.gh 66 Interviewers Statement I, the undersigned, have explained this consent to the subject in English language that s/he understands the purpose of the study, procedures to be followed, as well as the risks and benefits of the study. The participant has fully agreed to participate in the study. Signature of Interviewer:…………………….Date……………………… Address:…………………………………………………………………. University of Ghana http://ugspace.ug.edu.gh 67 Appendix 2 Structured questionnaire ASSESSING THE QUALITY OF ANTENATAL CARE IN NKWANTA SOUTH DISTRICT Interview date:____/____/______ District: _________________________Sub- district_____________________________ Facility type: 1. Hospital 2. Health centre/clinic 3. CHPS compound Name of Interviewer: ______________________________________________ Respondent’s Number: NO QUESTIONS RESPONSES SKIP BACKGROUND RESPONSES Q1 What is your age? (in complete years) Q2 What is your marital status? (Tick one) 1. Married 2. Single 3. Divorced 4. Widowed Q3 What is your highest educational level? (Tick one) 1. No formal schooling 2. Primary 3. Secondary 4. Tertiary Q4 What is your religious affiliation? (Tick one) 1. Muslim 2. Christian 3. Traditionalist 4. Other specify …………… Q5 What is your occupation? (Tick one) 1. Student 2. Apprentice 3. Unemployed 4. Farmer 5. Trader 6. Self employed 7. Government employee 8. Other specify ……….. ANC ATTENDANCE Q6 Is this your first pregnancy (Tick one) 1. Yes 2. No Q7 Is this your initial or follow up visits with this pregnancy? (Tick one only) 1. Initial visit 2. 2nd visit 3. 3rd visit University of Ghana http://ugspace.ug.edu.gh 68 4. 4th visit 5. Other specify …. Q8 About how many times have you visited this facility with this pregnancy? (Tick one only) 1. Once 2. Twice 3. Tree times 4. Fourth time 5. More than four times Q9 What history does the care provider take from you when you came to the clinic today? Probe for the following; (Probe and tick as many as possible) 1. Personal history 2. Social History 3. Family history 4. Medical history 5. Surgical history 6. Obstetric history 7. History for current pregnancy 8. Breast feeding Q10 What examinations does the health care provider perform on you during your stay with her in the room? Probe for; (Probe and tick as many as possible) 1. Blood pressure 2. Weight 3. Pallor 4. Edema 5. Breast 6. Fundal height 7. Fetal presentation 8. Listen to fetal heart sound 9. Hemoglobin 10. Grouping and cross matching 11. Rhesus factor 12. VDRL 13. Urine for: protein 14. Sugar 15. HIV testing Q11 What prophylactic drugs and immunizations were you given? (Probe and tick as many as possible) 1. Iron tablets 2. Folic Acid 3. IPT 4. TT immunization Q12 What information does the care provider give to you during education and counseling? (Probe for and tick as many response given) 1. Process of pregnancy and its complication 2. Diet 3. Personal hygiene 4. Danger signs in pregnancy Exclusive breast feeding 5. Harmful habits e.g. drug abuse, smoking, taking traditional medicine University of Ghana http://ugspace.ug.edu.gh 69 6. Schedule for next visit 7. Plan for postpartum 8. Effects of STI 9. Effects of HIV and STI 10. Plans for delivery EMPATHY Q13 How will you rate the readiness of the staff to listen to your problems? (Tick one only) 1. Poor 2. Fair 3. Good 4. Very good Q14 How will you rate how the staff cared about you as a client? (Tick one only) 1. Poor 2. Fair 3. Good 4. Very good COMMUNICATION Q15 Did the health care provider tell you what was wrong with you? (Tick one) 1. Yes 2. No Q16 Did the health care provider explain your situation for you? (Tick one) 1. Yes 2. No Q17 Did health care provider give you instructions about what to do next? (Tick one) 1. Yes 2. No Q18 For your visit(s) how would you rate your experience of how clearly health care providers explained things to you? (Tick one only) 1. Poor 2. Fair 3. Good 4. Very good Q19 For your visit(s), how would you rate your experience of getting information about other types of treatment? (Tick one only) 1. Poor 2. Fair 3. Good 4. Very good COMPETENCE Q20 In your opinion did the health care provider examine you to your satisfaction? (Tick one) 1. Yes 2. No Q21 In your opinion, was the health care provider’s skill adequate for your visit? (Tick one) 1. Yes 2. No AVAILABILITY OF RESOURCES Q22 Were you given some medications to take under the observation of the health care provider? (Tick one) 1. Yes 2. No Q23 Did you understand the instructions about the drugs given to you today (Do you know what the medications were meant to do for you? (Tick one only) 1. Yes 2. No Q24 Did the health care provider prescribe University of Ghana http://ugspace.ug.edu.gh 70 any medicine for you to buy elsewhere besides the ANC clinic? (Tick one) 1. Yes 2. No Q25 Of the medicines that were prescribed for you, how many of them were you able to get? (Tick one only) 1. All of them 2. Most of them 3. Some of them 4. None of them Q26 Which reason best explains why you did not get all the medicines prescribed for you? (Tick one only) 1. Could not afford 2. Could not find all 3. There is none at the facility 4. Other specify………… Q27 In your opinion, were the drug supplies adequate for your condition? (Tick one) 1. Yes 2. No TANGIBLES Q28 For your visit, how would you rate the cleanliness of the facility? (Tick one only) 1. Poor 2. Fair 3. Good 4. Very good Q29 How neatly appearing are the staff of the facility? (Tick one only) 1. Poor 2. Fair 3. Good 4. Very good Q30 In your opinion, was the health care provider’s equipment adequate for your antenatal care services? (Tick one) 1. Yes 2. No Q31 For your visit how would you rate the comfort of the waiting area? (Tick one only) 1. Poor 2. Fair 3. Good 4. Very good RESPONSIVENESS Q32 For your visit, how would you rate the amount of time you waited before being attended to? (Tick one only) 1. Poor 2. Fair 3. Good 4. Very good Q33 For your visit, how would you rate your experience of being greeted and talked to respectfully? (Tick one only) 1. Poor 2. Fair 3. Good 4. Very good Q34 For your visit how would you rate the way your privacy was respected during physical examination ? (Tick one only) 1. Poor 2. Fair 3. Good 4. Very good Q35 For your visit, how would you rate your experience of getting enough time to ask questions about your care/problems if any? (Tick one only) 1. Poor 2. Fair 3. Good 4. Very good Q36 For your visit, how would you rate your experience of being involved in making 1. Poor 2. Fair University of Ghana http://ugspace.ug.edu.gh 71 decisions about your antenatal health care? (Tick one only) 3. Good 4. Very good Q37 For your visit, how would you rate the way the health services ensured you could talk privately to health care providers? (Tick one only) 1. Poor 2. Fair 3. Good 4. Very good Q38 For your visit, how would you rate the way your personal information was kept confidential? (Tick one only) 1. Poor 2. Fair 3. Good 4. Very good Did you feel that you were treated badly by the health care providers at the antenatal clinic because of your? (Tick one for Q39 - 43) Q39 Age 1. Yes 2. No Q40 Social class 1. Yes 2. No Q41 Type of visit 1. Yes 2. No Q42 Condition 1. Yes 2. No Q43 Type of Problems/illness 1. Yes 2. No OVERALL SATISFACTION Q44 In general, would you say you are? (Tick one only) 1. Not satisfied 2. Somewhat satisfied 3. Satisfied 4. Very satisfied OVERALL RATING OF QUALITY Q45 In general how would you rate the quality of care you have received during today’s visit? (Tick one only) 1. Poor 2. Fair 3. Good 4. Very good Q46 Would you want to come to this facility again before you deliver? (Tick one) 1. Yes 2. No Q47 Where would you deliver your baby? (Tick one only) 1. Public health facility 2. Private health facility 3. TBA 4. Relative/Home 5. Other specify…………. University of Ghana http://ugspace.ug.edu.gh 72 Appendix 3 Observation checklist ASSESSING THE QUALITY OF ANTENATAL CARE IN NKWANTA SOUTH DISTRICT Interview date:____/____/______ District: _______________________Sub-district__________________________ Facility type: 1. Hospital 2. Health centre/clinic 3. CHPS compound Name of Observer/ Interviewer: _ OBSERVATION CHECLIST NO ITEM YES NO REMARKS Part A: Facility and Supplies Facility and Supplies checklist Q1 General infrastructure Space available in the waiting area Cleanliness of the building- Examination area Q2 Facilities sanitation Bathroom Toilet Sluice rooms Q3 Privacy Q4 Adequate light Q5 Tables, chairs for daily activities Q6 Number of examination coaches Q7 Infection prevention measures taken Hand washing Decontamination Cleaning High level disinfection Sterilization Alcohol spirit swabs present Gloving Q8 Drugs Anticonvulsant Magnesium Sulphate Anti malarial Ferrous sulphate Q9 Intravenous fluid N/ saline University of Ghana http://ugspace.ug.edu.gh 73 Lingers Lactate Dextrose Giving set Cannulaes Availability of supplies/ Cleaning materials Disinfectants Syringes and needles Stationary/ HIMS tools Linen Gloves Sterile Disposable Heavy duty Soap for hand washing Other supplies Specify………………… Q10 Means of Communication Telephone wireless massage Any other means Q11 Availability of Emergency guidelines available (list them) Part B Observation of antenatal care process Designation of Antenatal service provider Name of the health facility Number of health caregivers at the ANC clinic No of Doctors available for ANC No of Midwife (s) Registered nurses CHO/CHN Enrolled Nurses Cleaners Ward Attendant University of Ghana http://ugspace.ug.edu.gh 74 INSTRUCTIONS: PLEASE TICK THE APPROPRIATE BOX ANY ACTION OBSERVED Yes No Q12 Does the midwife start clinic according to schedule Does the midwife greet client respectfully Registration with client using HIMS Comprehensive history taking Social history Family history Past medical/ surgical history Past obstetric History Past breast feeding history Information of present pregnancy Q 13 Observation and clinical investigation checks blood pressure checks weight observes gait Physical Examination Prepares materials necessary for examination Ensures privacy Prepare client for physical exam Washes hands before examination Q14 Conducts head to toe examination CIRCLE THE APPROPRIATE OBSERVED Head Pallor Neck Hands Legs for pedal edema Vulva inspection for soft tissue Genital ulcers Vaginal discharge Bleeding Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No Q15 Foetal Examination CIRCLE THE APPROPRIATE OBSERVED Inspects abdomen for any abnormalities Estimates fundal height Checks fetal presentation Checks engagement of presenting part Listens and counts fetal heart sounds Conducts pelvic assessment (cephalo pelvic relationship at 36 weeks of gestation for primigravida Yes Yes Yes Yes Yes Yes No No No No No No University of Ghana http://ugspace.ug.edu.gh 75 Communication with client throughout the procedure and gives her feedback on findings of physical, obstetrical and any other procedures done Yes No Q16 Laboratory investigation CIRCLE THE APPROPRIATE OBSERVED blood for ; - Hemoglobin - Grouping and cross matching - Rhesus factor - VDRL - Syphilis blood for - Protein - sugar -Acetone Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No Q 17 Breast Examination CIRCLE THE APPROPRIATE OBSERVED Inspection Palpation Preparation for breast feeding Yes Yes Yes No No No Q 18 Drug administration (what is given for) CIRCLE THE APPROPRIATE OBSERVED Malaria………………. Hemoglobin booster Folic acid Iron sulphate Tetanus Toxoid Vaccine Sterile procedure followed Yes Yes Yes Yes Yes Yes No No No No No No Q 19 Client education and counseling given to client daily before being examines on any of the following: CIRCLE THE APPROPRIATE OBSERVED Process of labor Diet nutrition Minor disorders Personal hygiene Danger signs in pregnancy Exclusive breast feeding Harmful habits Smocking Drug abuse Alcoholism Traditional herbs to induce labour Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No University of Ghana http://ugspace.ug.edu.gh 76 Plans for Place of delivery Post natal care Schedule for next visit Effects of STI STI/HIV/AIDS Yes Yes Yes Yes Yes No No No No No Q 20 Does the midwife refer at risk client with abnormal findings to high health facility Yes No Q 21 Does the care provider schedule subsequent visit Yes No PLEASE RE-VISIT QUESTIONS LEFT BLANK University of Ghana http://ugspace.ug.edu.gh 77 Appendix 4 Focus group discussion guide ASSESSING THE QUALITY OF ANTENATAL CARE IN NKWANTA SOUTH DISTRICT FOCUS GROUP DISCUSSION GUIDE Focus group discussion for mothers with children less than six months who attended ANC but delivered at anywhere of their choice. My name is _____________________________ and I am here with Joseph Degley, a resident of School of Public Health , Legon. We want to welcome you ladies to this gathering. We are here to know your opinion about quality of health care you received during your antenatal care visit. Particularly about the things you observed and experienced. We want you to feel free to say all that you want to say. What you say here today will help us understand and plan to improve on health care services in the district provide. Information provided or issues discussed here will be treated confidentially. Ground rules: There are no right or wrong answers in this discussion. All what shall be said is important for us. All our discussions will be recorded on tape so that we can refer to it later. We shall also write down notes. Participants shall introduce themselves; Rules for the discussion: One person will talk at a time so that we can all hear clearly and then give our comments when she is done; you may ask questions for clarification; University of Ghana http://ugspace.ug.edu.gh 78 You may stop me for comments or contribution as the discussion goes on; we must try to finish within an hour. The demographic questionnaire for the women included questions pertaining to age, tribe, level of education, number of children, level of education, place of delivery of last pregnancy and employment status. 1. Describe to us what quality of Antenatal care means to you. 2. What does satisfaction mean for you? 3. Please describe to us what you consider more important during your visit to the antenatal clinic. 4. Please describe to us what you expect from the hospital and health care personnel during ANC visit. 5. Please describe to us how you feel during your visit to the antenatal clinic when you were pregnant. 6. Please describe to us what you would like to improve in antenatal care. 7. What are the factors that cause your feelings of satisfaction or dissatisfaction? 8. What made you to deliver your last child at the place you delivered? 9. What are the factors that cause you to rate the care you received at ANC as high quality or low quality? 10. Please describe to us how you would rate the care you received at ANC when you were pregnant with your last child? University of Ghana http://ugspace.ug.edu.gh 79 Appendix 5 Verbatim transcription of FGD sessions STUDY FINDINGS – FGD SESSIONS Demographic characteristics of participants A total of 40 participants from 4 communities participated in the FGD sessions. The participants were community women with children less than 6 months of age. The demographic questionnaire for the women included questions pertaining to age, tribe, level of education, number of children, level of education, place of delivery of last pregnancy and employment status. Approximately more than half (64.3%) of the women had delivered at home. The age of participants ranged from 15 to 45 with a mean of 26.5 years. The ranges and means by site were identical to the total population of women who participated. There was no tribal diversity among the various groups. Nearly 96 percent of the participants from all the 4 communities were married, and almost all reported being farmers. In looking at reported education levels of all women in the study, only three of the 40 women reported they did attend school up to the Junior High School level and four stopped at primary school. What quality of antenatal care meant to participants Similar themes were found at all the four FGD sessions. The knowledge exhibited by participants was found to be closely linked to the activities performed at the ANC. However, majority of them were skeptical about defining quality ANC. In the areas where ANC activities were vibrant, such as Nkwanta where the 2 major hospitals are located, the knowledge about quality ANC seemed to be high. This was how a woman at Alhaji Bankyi Zongo summarized quality ANC. University of Ghana http://ugspace.ug.edu.gh 80 “We cannot tell which care is quality because we believe the nurses and the doctors are trained to provide care that is adequate for the pregnant woman and the growing fetus. Therefore whatever care they provide to us is assumed to be of the highest quality available. We cannot compare any of our facilities here (in this district) to facilities in Accra or any other big cities. For me, all the health care providers undergo the same kind of training however, equipment at the facilities differ. The cities are endowed with good and modern equipment. The equipment in our facilities are not up to the required standard. If our health care providers are given the required equipment, some can even perform better than those in the big cities” (woman, Alhaji Bankyi Zongo) What satisfaction meant to participants Participant described satisfaction as inherent and subjective depending on situations in which one finds herself in. Consequently, several definitions were allotted for satisfaction in ANC. The following are some of the interesting descriptions of satisfaction. ”As for me satisfaction is when my health problems are solved at the facility. When I am sick and go to the hospital and the health care providers give me medication and I am healed, I am satisfied, and I think this is the reason why anybody would go to the hospital in the first place” (woman, Odomi). “Why go to the hospital at all, it is to get relieve from your sickness. Therefore if you go there and you are cured or the pains you‟ve been having before is gone, you should be more than satisfied” (woman, Dogoketewa). “Though the pain may be gone I would not be satisfied because of the time wasted and the behaviour of some of the health care providers. Some of the health care providers University of Ghana http://ugspace.ug.edu.gh 81 think we did not go to school so we are nobody. You go to hospital with common headache and you spend the whole day at the facility. Why? Are the workers not paid to manage time?” (woman, Alhaji Bankyi Zongo). “My colleagues have said all, but the little I will add is that, satisfaction at ANC depends on the individual. For me when I went to the facility and I was told my fetus was healthy and I was healthy too, I was very happy and extremely satisfied. After all our health care providers in this part of the country (Nkwanta District) are doing their best with the limited resources they had to work with” (woman, Dadieso). Services participants considered more important during ANC visits All respondents from the different communities considered the safety of their unborn babies (fetus) as the one most important reason for attending ANC. Very few considered the education they received from the health care providers as most important. Their responses reflected in some of the quotes from the FGD sessions. Women from all the communities also mentioned ANC was important in the case of prenatal complications. “The most important thing at the ANC is to be sure the fetus is in good health” (woman, Dogoketewa). “The things I considered most important thing at ANC were the medications the health care providers gave especially the injections and anti-malarial to keep mother and baby in the womb healthy in order to deliver safely” (woman, Odomi) “At ANC, the most important thing was that, I underwent scan and it made me know that the baby in my womb was healthy. What else could be more important that these”? (woman, Alhaji Bankyi Zongo) University of Ghana http://ugspace.ug.edu.gh 82 “It was when the health care provider made me lie down on the small bed (couch) and she used a tape measure to measure my stomach (abdomen) and used something like funnel (fetuscope)to listened to the babies voice (fetal heart sounds) to make sure the baby in my stomach (womb) was healthy. Health care providers are actually doing a great job. Just that our facilities lack the appropriate equipment” (woman, Dadiese). Women’s expectation from the health facility and health care personnel during ANC visit Major expectations for attending the facility for ANC services were to monitor the health of mother and baby (vital signs), receive advice about prenatal care including diet, exercise and to acquire additional medical care and health promotion materials. This includes vitamin supplements, HIV tests, and mosquito-nets for malaria prevention, receive immunization and medications and finally be respected by the health care providers. “I was expecting the health care providers to make sure I was healthy at all times until I was due for delivery and my delivery should be in „peace‟ and the baby should be healthy. True to my expectation, everything went well for me, because my HIV status was checked, I had enough education on personal hygiene, I had immunization to prevent the baby from diseases” (woman, Dadieso). “I expected them to provide me with health care that was expected of people that have been trained by the government (professional). The care should be of high standard and in my estimation; I thought I had expert care” (woman, Odomi). “My expectation was to have myself and the baby inside me checked and the health care providers did that for me. They provided us with education, immunization, HIV test and University of Ghana http://ugspace.ug.edu.gh 83 asked us to have preparation plan for delivery. See my baby, she is healthy and I am healthy too. I am grateful to Allah that all my expectations came to pass” (woman, Alhaji Bankyi Zongo) “I expected the nurses to protect my baby in my stomach (womb) with drugs and immunizations. They (health care providers) gave all I expected them to do for me. I also expected them to treat us with respect. Some did that but some of them were disrespectful towards us when we visited the facility” (woman, Dogoketewa). Description of how participants felt during their visit to ANC with the immediate passed pregnancy. Majority of the respondents felt they were treated well by the health care providers; however others also felt they were taken advantage off by taking unofficial monies from them. Those who felt they were cheated explained that, though antenatal services were supposed to be free, health care providers insisted they go for National Health Insurance cards before accessing services. Those without the NHI cards were asked to pay for services. “I felt very relieved when I visited the ANC the first time with my last pregnancy. The nurse treated me very well. That encouraged me to be going there regularly until my last visit before delivery when the new nurse told me my NHI card expired so I should go to the NHIS office to renew it before I could be attended to. That day, „I cursed my star‟. The nurse was so rude towards me that I left the facility and went to another facility. For me so long as that nurse remains at that facility, I shall never go there again for services” (woman, Alhaji Bankyi Zongo). University of Ghana http://ugspace.ug.edu.gh 84 “You see, women become difficult especially when they become pregnant, that notwithstanding, pregnancy is a special period and pregnant women need to be handled with special care. I felt good when the doctor (male health care provider) talked to me politely. But as for the nurse (female health care provider) she is so rude and disrespectful. Therefore, I wait until the „doctor‟ is there before I go, when the nurse alone is around, I do not go there at all” (woman, Dogoketewa). Suggestions on what respondents thought should be improved at ANC. Majority of the respondents were of the view that, there was the need for infrastructural development as well as provision of equipment at the ANC sites. Other improvements they would like to see includes affectionate health care providers who communicate well with ANC attendants, free supply of basic items and drugs and increased staff at the facilities. “You see, a good workman with faulty or inadequate tools cannot give off the best of services, I would want to suggest that, all the facilities should be equipped with modern equipments to meet today‟s technological standards” (woman Alhaji Bankyi Zongo). “There is the need to improve a lot of things at the ANC sites. First of all, we need qualified persons at the facilities, some of us are aware that most of the ladies and gentlemen at the facilities are just school leavers on National Youth Employment Programme, they are not nurses but they are functioning as such. Others are ward orderlies and labourers but parading themselves as health workers. They need to be trained so that we can be safe in their hands. Secondly, equipments are important to improve health delivery. Thirdly, the structures need to be rehabilitated. Look there are University of Ghana http://ugspace.ug.edu.gh 85 lots of things to be done to improve ANC services, the list is inexhaustible” (woman Alhaji Bankyi Zongo). “As for me I think we can also help as a community to improve ANC services by embarking on communal labour to buy basic equipment for the nurse to use on us. Look, many people may not be happy with my suggestions but this is my opinion” (woman, Dadieso). “For me, human beings are the pre-requisite for every development and change. I wish we have health workers who are affectionate and communicate well with clients. If the facilities are stocked with basic items like drugs and the staffs are kind and affectionate, all would be right” (woman, Dogoketewa) Factors that cause satisfaction or dissatisfaction at ANC All the participants expressed their dissatisfaction at the long waiting time spent at the facilities and inadequate communication between clients and health care providers. Only a few expressed their satisfaction with the belief that the health care providers were competent in their service delivery. “In my opinion, patients spent too much time at the waiting area before being attended to by the health care providers. I think the health workers take delight in seeing patients struggling for space at their facilities. They would wait until the whole place is full and over-flowing before they would start attending to clients. If I have my way, all of them (health care providers) must undergo training in time management. What I am saying University of Ghana http://ugspace.ug.edu.gh 86 now is happening in all public health institutions in Ghana” (woman, Alhaji Bankyi Zongo). “You see, because they (health care providers) wait until the clients have no place to sit, they hurriedly see the clients and communication becomes defective. As for me, I do not think I shall ever go to ANC on a Monday again. When they (health care providers) wait until clients are over-flowing, they easily become irritated at the least provocation and shout at clients. They must start seeing clients early. During my last pregnancy, I quite remember, on a Monday, some of us had to leave without being attended to, because as at 5:00 pm many clients were still at the waiting area and there were only two nurses attending to clients” (woman, Dadieso). “You see, what else can we do, they (health care providers) are trained and I believe, they are competent in their field of profession. Therefore whatever care they provide, we have to be satisfied with it. For me, I am always satisfied with the care they (health care providers) provide” (woman, Odomi). “For me, long waiting time, shortage of drugs, inadequate staff, and poor communication between health care providers and clients cause dissatisfaction among ANC attendants. On the contrary, affectionate and empathetic health care providers are sources of satisfaction for ANC attendants” (woman, Dogoketewa) University of Ghana http://ugspace.ug.edu.gh 87 Decisions Surrounding Place of delivery of last pregnancy When a mother considers where to deliver, the decision-making process can be complex. She must weigh the advice from health care providers, friends, and family. There are culturally laden gender roles that empower family members to make this decision more than the mother herself. Further, when the larger social network is involved in making delivery decisions, delays can occur and the mothers may end up delivering at home. All respondents agreed that delivery services are sought in both health facilities and home environments, however, home births are common. “When a mother is in labor, she tends to rush to the nearest place where she can be assisted. Many of us delivered on their way to the health facilities. It was obvious that most mothers here delivered at home or with the assistance of a TBA” (woman, Odomi). “You see, during the time of labour, the pregnant woman herself barely takes any decision, the decision lies in the domain of immediately available relatives, even at times the decision lies with family members far away in another community, a lot of people have influence over decisions in place of delivery. Many at times delay in decision making results in women delivering at home” (woman, Dadieso) “In my view, women are to blame for delivering at home. For me, immediately I see the first signs of labour, I go to the hospital before informing people who matter. I think every woman should adopt this strategy” (woman, Alhaji Bankyi Zongo) University of Ghana http://ugspace.ug.edu.gh 88 Factors that make participants rate care received at ANC as high quality and low quality. The quality of each person’s care involves many different processes and stages provided by many different people, yet individual health care providers rarely see more than a snapshot of this care. Imperfect systems and resource constraints mean that staff constantly struggle against underlying deficiencies in the system. Although good outcomes are the objective of all health actions, outcomes alone are not an efficient way to measure quality for two reasons. The first is the quality puzzle. A patient may receive poor-quality care but may recover fully, or a patient may receive high-quality care for an illness such as cerebral malaria and still not recover. Second, adverse health outcomes are relatively rare and obviously do not occur with every encounter. “The processes one has to pass through at the ANC, many at times render a presumably high quality care dissatisfying. It is always obvious when quality health care is provided. The client becomes satisfied. In short, quality health care brings about satisfaction” (woman, Alhaji Bankyi Zongo) “As I have said earlier, I wish to reiterate my earlier submission that, what I have experienced and therefore describe it as quality may not be same with another person. Quality may be determined by health outcome at the facility. You may be given the best of care for an illness but the outcome may be death. Similarly, one can be given the poorest of care but the outcome may be good health” (woman, Alhaji Bankyi Zongo). “Of course, rude behaviour of nurses, shortage of medicines and long waiting time would make me rate care received at ANC as low quality. On the contrary, when drugs are available, waiting time is short, and our nurses are affectionate towards clients, then the care is of high quality” (woman, Dadieso) University of Ghana http://ugspace.ug.edu.gh 89 Participants rating of care received at ANC during their last pregnancy According to the participants, all of them at a point during their last pregnancy visited the ANC for care. Majority were of the view that the care they received was the best available at the facilities. Participants attributed long waiting time to circumstances beyond control of the staff. On a Likert-scale of Poor, Fair, Good and Very good, all the participants rated ANC care received during their last pregnancy as Good. “Health care providers were performing their services in the wake of numerous constraints, majority of the constraints were beyond their control. If I were to rate the ANC services I received during my last pregnancy out of 100%, I would give them 75%” (woman, Alhaji Bankyi Zongo) Results from FGD sessions with women bearing children less than 6 months of age also revealed that similar themes were found at all the four FGD sessions. The knowledge exhibited by participants was found to be closely linked to the activities performed at the ANC. However, majority of them were sceptical about defining quality ANC. In the areas where ANC activities were vibrant, such as Nkwanta where the 2 major hospitals are located, the knowledge about quality ANC seemed to be high. This was how a woman at Alhaji Bankyi Zongo summarized quality ANC. “We cannot tell which care is quality because we believe the nurses and the doctors are trained to provide care that is adequate for the pregnant woman and the growing foetus. Therefore whatever care they provide to us is assumed to be of the highest quality available. We cannot compare any of our facilities here (in this district) to facilities in University of Ghana http://ugspace.ug.edu.gh 90 Accra or any other big cities. For me, all the health care providers undergo the same kind of training however, equipment at the facilities differ. The cities are endowed with good and modern equipment. The equipment in our facilities are not up to the required standard. If our health care providers are given the required equipment, some can even perform better than those in the big cities” (woman, Alhaji Bankyi Zongo) University of Ghana http://ugspace.ug.edu.gh 91 Appendix 6 Ethical clearance University of Ghana http://ugspace.ug.edu.gh